When buying Electronic Medical Record (EMR) Software which is better: ASP or Client/Server? Unfortunately, there is no right answer. You’ll need to decide what’s important to your practice and what’s not. In this article we’ll explore the advantages and disadvantages of each model so you’ll be able to make an educated decision when the time comes to purchase an EMR software solution.
ASP is a remotely hosted software system accessed via an internet web browser, similar to the model used in online banking. This remotely hosted system is accessed by paying a rental or service fee. The server is secure and HIPPA compliant and is not located in your office. All technical aspects of the server are managed by a professional IT company, and you pay a monthly access fee (or per occurrence fee) for the services of this IT company. The cost of an ASP-based system is relatively low in the beginning, however, because the fees never stop the cost over the long term adds up and usually ends up being more expensive than using a Client/Server-based system.
One of the other benefits of the ASP-based system is that almost all computing is done on the remote server, thereby reducing the minimum computer hardware requirements on the clients/workstations. ASP allows you to access all of your information at any time, from any place with internet access. Like all comparisons with advantages come disadvantages. Loss of customize- ability; the host server is being accessed by many different users. Although your data is secure, your individual customized needs are not met as readily as you may desire. One of the other disadvantages is that an ASP system does not move as quickly as a Client/ Server system. This is an important factor to consider with point n’ click intensive Electronic Medical Record software as vital time may be lost by waiting for data to transfer over the internet; these seconds can quickly add up to minutes and hours in a couple weeks time. Accountability issues are a deep consideration to ASP. Company service degradation is felt more acutely and such things as vendor bankruptcy could have a more drastic impact on the practice as a whole. Periodically check the stability of the EMR software vendor, and ask for a back up copy of your data for your own records.
Client/Server models allow for quicker response times in the application as data from the server to the client is transmitted much faster (usually 100 Mbits/second). The newer client/server products developed in Java and Microsoft.Net are capable of offering the “best of both worlds” as they have the speed of a local system plus the accessibility from a remote location. Where traditional client/server products required practices to use MS Terminal Services or Citrix technology to access their data from remote locations, these newer systems can be accessed from any internet browser. Client/ Server also boasts the benefits of the practice having control over their data. However, with this control comes responsibility; the responsibility of being responsible for your data as you are now open to the risk of theft, fire, hard-rive failure, and data corruption.
Many IT futurists consider ASP-based systems to be the future. However, many offices find they don’t have the need for remote access and don’t want to put their data in the hands of another company making client/ server systems still a popular option. In most cases, if an office has multiple locations an ASP system should always be considered but if an office requires high-performance and doesn’t have multiple locations the client/server system may be the better option. Speak with your IT consultant and the software vendor to get all the facts you need to make an educated decision.
To recap, WITA™ is a sophisticated wound analysis, assessment and care management software solution allowing clinicians, carers and researchers to quickly and intuitively analyse wounds, manage the ongoing care of patients and maintain the integrity & accountability of the diagnosis. To add value to this process and enhance patient recovery, WITA™ will also provide SMART treatments aligned to a hospital’s formulary and even scan the market for alternative treatments.
It has a unique image analysis tool that takes the visual properties of a wound image and applies an advanced statistical pattern recognition algorithm. The result is a quick analysis of a wound providing accurate tissue and dimension data, which is stored in an interactive wound diary.
Please click here for our video testimonial on the WITA website or visit us here on our youtube.com page.
Contact us
For information regarding Pricing, Support Levels, Installation & how we can help integrate WITA into your clinic please email chriskennedy@imagocare.com or call 0208 668 6084
Implementing the new CMS guidelines for wound care: areas for potential citations are explained by Jeffrey M. Levine, MD, AGSF, CMD; Marilyn Peterson, RNC, MSN; and Fay Savino, RN, BSN, MA.
The Centers for Medicare & Medicaid Services' (CMS) new pressure ulcer guidelines for surveyors have arrived. (1) Federal Tag 314 (F314) is replaced completely by a 40-page document that vastly expands protocols for investigating pressure ulcers (see tables 1 and 2 for F-tags applicable prior to and in the new CMS guidelines). (2) In addition, surveyors are directed to consider other F-tags during investigations for compliance. The volume of detail written into the new F314 is extraordinary and essentially amounts to a "clinical practice guideline" for wound care directed to both facility staff and surveyors. Along with the Quality Measures posted on CMS's Nursing Home Compare Web site (www.medicare.gov/nhcompare/home.asp), these guidelines increase the incentive for facilities to strengthen their wound care programs.
We suggest that facilities first become familiar with the guidelines, and then completely review their internal systems for wound care, including the policy and procedure (P & P) manual. Good wound care is dependent on many aspects of the care process, and this is reflected in the new CMS guidelines, which include emphasis on resident assessment and care planning. New citations are added for lack of physician and medical director involvement with wound care, as described below. Since emphasis is added on physician notification and the correct use of products, internal review should include the responsiveness and effectiveness of physician services. Remember that wound care is interdisciplinary and includes not only medicine and nursing but also nutrition, rehabilitative services, and social work.
Risk Assessment
Risk assessment is an important component of any wound care program. Risk assessment for pressure ulcers should be performed on every resident upon admission along with a complete body check for preexisting ulcers. The Braden Scale is a popular measure, although others are available. (3) Whatever scale is employed, it should be administered upon admission, then weekly for one month, and then quarterly. Because the risk for pressure ulcers rises with changes in medical status, the risk-assessment scale should be repeated whenever a medical illness or change in status occurs, including such events as stroke, delirium, fracture, new onset of diabetes mellitus, or any infection, such as UTI or pneumonia.
Accuracy is critical when performing a risk assessment. When the medical record is reviewed by a surveyor, each subscale should correspond accurately to the patient's condition at that time. Therefore, in-services on use of the assessment scale are important components of the wound care program. Conduct in-services for all nurse managers and other individuals delegated the task of completing the scale. Quality assurance (QA) review is recommended to ensure accurate determination of the subscales.
The system for documentation of risk requires facility-wide review, beginning with review and revision of the P & P manual and the charting system's organization. An important consideration is the construction of the medical record for ease of review. Risk-assessment results should be congregated in a separate section, thereby allowing for ease of retrospective review of documentation timeliness and accuracy by QA and survey personnel. An alternative method is to place the risk-assessment documentation within the interdisciplinary notes in a clearly marked entry.
[ILLUSTRATION OMITTED]
The Prevention Plan
The facility should maintain an armamentarium of prevention modalities for residents deemed at risk for pressure ulcers. The most basic is the turning and positioning schedule, which is supplemented by pressure-relief solutions such as heel pads, seating cushions, mattress overlays, and specialty mattresses. (4) The new CMS guidelines contain an introduction to support surfaces, including static and dynamic pressure-reduction devices. Static pressure redistribution devices simply are cushioned surfaces, while dynamic devices have intrinsic movement. An example of a dynamic pressure-reduction surface is the alternating pressure air mattress.
The basic turning and positioning schedule is every two hours, but some patients at risk require even greater frequency because of compromised tissue tolerance. (5) Whether or not the facility's P & P manual requires documentation with turning and positioning flow sheets, an auditing system must exist to enforce facility-wide compliance with turning once a resident is deemed at risk.
Several resident characteristics affect the ease of enforcing a turning schedule. Residents with feeding tubes or those on ventilators, for example, may not be turned in the same manner as those not attached to life support. Residents with contractures can be turned but may need specially positioned pillows or cushions to maintain proper pressure relief. Thus, an individualized care plan can provide a guide to pressure-relief management.
Mobilization strategies are always a component of pressure-sore prevention. These include physical therapy and occupational therapy involvement for body strength improvement, balance training, and adaptive equipment. These therapists often are able to provide suggestions for proper seat cushions and positioning devices. A speech therapy consult is helpful when determining ability to swallow and the need forspecialdietsand therapies.
An individualized care plan should be constructed for each resident deemed at risk by the risk-assessment scale. This care plan should take into consideration factors that interfere with pressure relief, such as the life-support modalities mentioned above, and should address pressure-relief devices currently in use. Incontinence management for relief of moisture and fecal contamination is a must in any skin-management plan. In addition, the care plan should address nutrition and refer to the appropriate section of the medical record that covers this. It is important for QA efforts to review the appropriateness as well as the timeliness of care plan interventions.
Ulcer Documentation and Treatment
Pressure sore documentation should begin upon admission if a pressure ulcer is present, preferably within 24 hours of the resident's entering the facility. Once an ulcer is detected, whether the resident is admitted with one or it is facility-acquired, a physician should perform a timely examination. Residents with pressure sores usually require review of their medical problems and a nutrition consultation, and the new CMS guidelines contain revised pressure ulcer investigative protocols that specifically target physician notification for changes in the resident's condition or wound(s).
A pressure sore's location can sometimes assist in pinpointing system problems that require intervention. For example, bilateral ischial ulcers frequently result from improper seating. Ulcers on the perineum that are surrounded by dermatitis may indicate fungal infection or inadequate continence care.
The first step in proper wound documentation is determining the correct diagnosis. The new CMS guidelines specifically mention arterial/ischemic ulcers, venous insufficiency ulcers (formerly known as the stasis ulcer), and diabetic neuropathic ulcers. It is critical that the diagnosis be made as early as possible and that the diagnostic process be carried forth with all disciplines, not only for surveyors and QA, but also for risk-management purposes. We therefore advise obtaining a physician consultation for assistance with diagnosing lower extremity ulcers and for clarification of ulcer type. Noninvasive vascular studies can be of crucial assistance in documenting ulcers associated with peripheral vascular disease. Consistency of documentation is important: If an ulcer is designated a pressure ulcer in one place and an arterial/ischemic ulcer elsewhere, this may spell trouble when a surveyor investigates the resident.
For documentation purposes, simply stating the stage of the ulcer is insufficient. Description of the wound should be accompanied by measurements of length, width, and depth, as well as notation of odor and presence of drainage. The new CMS guidelines contain specific definitions of tunneling, sinus tract, undermining, eschar, slough, exudate, and granulation tissue. These definitions, as well as the staging system, need to be understood by staff entering wound documentation into the medical record. The best documentation contains not only stage and measurements, but also a narrative description of the wound, current treatment, and response to treatment. It is helpful to document the treatment in progress and the rationale for that treatment (i.e., absorbs drainage, treats infection, protects surrounding skin, debrides eschar, etc.).
Documentation in the medical record should be organized to facilitate QA and/or surveyor review. As with the risk-assessment results discussed above, we recommend congregating the wound care flow sheets and documentation in a separate section. This, however, does not eliminate the need to discuss wound prevention and care in the narrative nursing notes.
The presence of pain is an important consideration when caring for wounds, and this is indeed reflected in the new CMS guidelines. Pain can result from the wound itself or can be a consequence of prevention measures or treatment. (6) Turning and positioning a frail resident witharthritisand contractures can be painful for him/her. Dressing changes can induce pain, with positioning of the resident and removal of adhesives. Pain should be assessed and described in the wound documentation note and addressed in the care plan and physician record.
Photographs can provide excellent supplementary documentation of wounds but should never take the place of written descriptions. Each facility must decide whether photographs should be part of its wound care documentation program. This decision should not be taken lightly, as the incorporation of photographs into wound care documentation is a decision that will require new P & Ps, staff training, expenses for a camera and printing, and incorporation of the photographs into the charting system.
Physician Involvement and Wound Care Formulary
The previous CMS guidelines to surveyors were silent on the issue of physician involvement in wound care. A surveyor now is advised to investigate related F-tags for associated citations such as not notifying the physician of changes (F157), not using correct products (F281), not providing adequate physician supervision for wound care (F385), and not involving the medical director in the wound care program (F501) (table 2). Facilities therefore have ample incentive to get their medical directors on board with reviewing and implementing a stronger wound care program, and educating their physicians about wound assessment and the correct use of products.
The medical director is delegated the task of supervising the primary care physicians in their wound assessment and documentation. All too often, primary care physicians rely on the nursing staff to perform wound assessments and decide on treatment modalities. The physician assessment should reflect the presence and location of the wound, as well as treatment and response to care. The medical documentation also should discuss conditions such as diabetes mellitus, peripheral vascular disease,weightloss, and stroke, which may adversely affect response to treatment.
Primary care physicians should be familiar with advanced wound care modalities and their proper use. The new CMS guidelines state, "[N]ot all products are appropriate for all pressure ulcers. Wound characteristics should be assessed throughout the healing process to assure that the treatments and dressings being used are appropriate to the nature of the wound." The facility should review its formulary for wound care products and make sure that the products are used properly. To accomplish this goal, a restricted formulary may be advantageous, with in-services for physicians and nurses on appropriate use. Efforts should be made to keep these products in stock to avoid delays when treatments are needed.
Was the Ulcer Avoidable?
The new CMS guidelines contain new detailed wording for surveyors to define whether an ulcer was avoidable or unavoidable. In addition, the investigative protocols present detailed instructions for inquiry into wound prevention, interventions, care plan revisions, and staff interviews to determine citations. The new CMS definition for "avoidable" is as follows:
"Avoidable" means that the resident developed a pressure ulcer and
that the facility did not do one or more of the following: evaluate
the resident's clinical condition and pressure ulcer risk factors;
define and implement interventions that are consistent with resident
needs, resident goals, and recognized standards of practice; monitor
and evaluate the impact of the interventions; or revise the
interventions as appropriate.
For ulcers that develop or worsen within the facility, we recommend a comprehensive narrative note that summarizes what was done to prevent the ulcer and/or what was done to stop it from getting worse. This note preferably should be written by the medical director and should incorporate information regarding the resident's underlying medical condition,nutritionalstatus, and advance directives. To facilitate the surveyor's review, this note should refer to specific dates that interventions were performed and where the information can be found.
Reverse Staging and the PUSH Tool
"Reverse staging" and the Pressure Ulcer Scale for Healing (PUSH) Tool are discussed in the new CMS guidelines, and these items bear some clarification and discussion. Experts agree that a wound does not heal in a reverse sequence (i.e., stage IV to stage III to stage II, etc.). The National Pressure Ulcer Advisory Panel (NPUAP) has taken the position that once an ulcer has reached an advanced stage, that ulcer should not be "downstaged" as it heals; NPUAP says that in the ulcer documentation, this lesion should be referred to as a "healing stage IV" rather than downstaging to stages III, II, or I. However, this position is at odds with the requirements of the RAI User's Manual Version 2.0, which instructs staff to code ulcers using standard staging criteria. We therefore recommend that nursing facility staff describe ulcers as they appear and not employ the NPUAP recommendation to avoid downstaging. Whatever staging system is used, it should be stated clearly in the facility's P & P manual.
NPUAP has advocated the use of the PUSH Tool, which offers the advantage of calculating a single numeric value for an ulcer, combining scores for length, width, exudate, and presence of eschar. (7) This tool does not supplant regular staging, measurement, and a narrative description of the wound. The PUSH Tool is optional and will require additional flow sheets, education, and training; revision of wound care P & Ps; and QA activities to ensure that the tool is being used correctly. Facilities should carefully consider this tool and determine whether it fits with their wound care program.
Nutrition and hydration comprise a substantial part of the new CMS guidelines, referencing other F-tags including F325 (Nutrition) and F327 (Hydration). The guidelines present a concise review of the importance of nutrition to skin integrity and wound care, and provide an overview of nutritional management, including recommended caloric intake and relevant laboratory tests. The new guidelines send a clear message that the nutritionist cannot take a backseat in the wound care process. Nutritional assessments for residents at risk for or having wounds should be timely, with special attention to malnutrition and weight loss, with provision of proper calories and fluids. (8) Wounds may take a long time to heal, and the nutritionist cannot wait until the next quarterly MDS assessment to reassess the resident. We recommend that the nutritionist engage directly with wound care personnel. Also, lines of communication between the nutritionist and physician should be strengthened.
Resident Choice and Advance Directives
The new CMS guidelines broaden the scope of pressure ulcer care by including issues of resident choice and advance directives. The guidelines recognize the right of the nursing home resident to make informed choices and refuse treatment. Facilities now are mandated to discuss the resident's condition, treatment, expected outcomes, and consequences of refusing treatment with either the resident or his/her legal representative. This concept is not new, as resident rights have been woven into the original Nursing Home Reform Amendments passed in 1987. What is new is the mandate to apply these concepts directly to ulcer care.
The guidelines also contain instructions that care must be delivered in accordance with residents' wishes as expressed in valid advance directives. There is a specific notation that a do not resuscitate order is limited only to resuscitative measures and is not applicable to other treatments and services. The incorporation of resident choice and advance directives into the CMS guidelines for wound care strengthen the mandate for resident and family education and inclusion in care plan meetings. Given the cognitive debility of many residents with pressure ulcers, as well as the complexity of end-of-life care decisions, the role of the social worker in wound care must be emphasized. The social worker is the team member who usually invites families to meetings and takes care of advance directives.
Summary
The new CMS guidelines to surveyors for pressure ulcers vastly expand the investigative protocols for wounds and add new F-tags for citing facilities for deficiencies in wound care. The guidelines cover risk assessment, documentation, monitoring, nutrition, advance directives, resident choice, and care planning. Areas for potential citations are expanded, including pain management, correct use of products, and physician involvement. There is now ample incentive to completely review and revise the facility's P & Ps for wound care. The medical director must be part of the team, and resources must be directed at implementing stronger oversight of the wound care program, including QA activities.
Jeffrey M. Levine, MD, AGSF, CMD, practices medicine in New York City at the Cabrini Medical Center. He is a Certified Wound Care Specialist, and he has served as a consulting expert oneldercareto the U.S. Department of Justice, the New York State Office of Professional Medical Conduct, and the Centers for Medicare & Medicaid Services.
Marilyn Peterson, RNC, MSN, is certified by the American Nursing Association in gerontological nursing. As a former director of nursing and assistant director of education in long-term care, she has a reputation as a leader and clinician with expertise in wound care, specialized care for dementia, and continuous quality improvement.
Fay Savino, RN, BSN, MA, has been active in healthcare since 1965, holding positions in direct care, nursing management, and regulatory compliance as a former New York State surveyor. She has been an LTC consultant since 1992.
For more information, contact Dr. Levine at (212) 253-5601. To send comments to the authors and editors, e-mail levine0905@nursinghomesmagazine.com. To order reprints in quantities of 100 or more, call (866) 377-6454.
References
1. Centers for Medicare & Medicaid Services. Guidance to Surveyors for Long Term Care Facilities. CMS Manual System, Pub. 100-07 State Operations, Provider Certification, Transmittal 4; November 12, 2004. Available at: www.cms.gov/manuals/pm_trans/r4som.pdf.
2. American Health Care Association. Guidance to Surveyors--Long Term Care Facilities. The Long Term Care Survey. Washington D.C.: American Health Care Association, 2002.
3. Seongsook J, Ihnsook J, Younghee L. Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale. International Journal of Nursing Studies 2004;41:199-204.
4. Sprigle S. The NPUAP Support Surface Standards Initiative. Ostomy/Wound Management 2004;50:6-8.
5. Agency for Health Care Policy and Research. Pressure ulcers in adults: Prediction and Prevention. AHCPR Publication No. 92-0047. Rockville, Md.: U.S. Department of Health and Human Services, 1992.
6. Popescu A, Salcido RS. Wound pain: A challenge for the patient and the wound care specialist. Advances in Skin & Wound Care 2004;17:14-20.
7. Pompeo M. Implementing the push tool in clinical practice: Revisions and results. Ostomy/Wound Management 2003;49:32-6,38,40 passim.
8. Schols JM, de Jager-v d Ende MA. Nutritional intervention in pressure ulcer guidelines: An inventory. Nutrition 2004;20:548-53.
Table 1. F-tags applicable to wound care in the prior CMS guidelines
Christopher Kennedy, a young entrepreneur from Purley, has just established a business, Imago Care, that procures the latest medical technology to distribute to the NHS, hospices, nursing homes, and individual community based customers.
His flagship product, Parafricta, a frictionless fabric is the first proven answer to the key nursing goal identified by EPUAP (European Pressure Ulcer Advisory Board), namely to "protect against the adverse effects of external mechanical forces: pressure, friction and shear on skin".The 25 yr old explained: "It is wonderful to be a part of a product that will revolutionalize the way to prevent pressure ulcers, treat dry skin conditions like eczema, keep wound dressings in place that are dislodged due to friction and to help gain these sufferers a better quality of life."
"Pressure ulcers cost the NHS around 2 billion every year and now there is a product that can reduce this cost dramatically. The fabric boasts properties that have already gain recognition by London's Science Museum. It has a coefficient of friction close to that of ice, almost as strong as steel, breathable, inert and can be washed up to 160 degrees with out losing any of its properties. "Parafricta™ Fabric products have been evaluated by more than 15 NHS sites in the UK including Great Ormond Street, where trials were conducted on children with fragile skin due to Epidermolysis Bullosa.
The results have confirmed that the garments and bedclothes prevent skin breakdown and progression to clinically detrimental pressure ulcers.Imago Care has also procured other leading products that aid in the treatment of chronic and acute wounds. For more information please call 0208 668 6084 or visit www.imagocare.com.
I came across this very insightful post that I thought I would direct your attention to.
VASCULAR ASSESSMENT
The vascular assessment will answer the question “Does the wound have enough blood supply to heal?” Healthy tissue is bright, beefy red, shiny, and granular with a velvety appearance. Tissue with poor vascular supply is pale pink or blanched to dull, dusky red color.
Physical vascular assessment includes: peripheral pulses, temperature, presence or absence of hair, mild to severe pain, rest pain, edema, and gangrene. The vascular assessment should also include:
Pallor: White, pale, blanched color of a limb when in the upright position.
Rubor: Dark purple to bright red color of a limb when in a dependent position.
Intermittent claudication: Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance. This suggests intermittent claudication and is caused by muscle ischemia.
Mottling or mottled skin: Irregular patchy skin coloring. Refers specifically related to blood vessel changes in the skin which cause the patchy appearance. This may indicate vascular insufficiency.
Capillary refill: The measurement of the rate of blood refill in empty capillaries . Measured by pressing a nail bed or area of tissue until it turns white and then timing until the return of color once the pressure is released. Normal refill time is less than 2 seconds.
Diagnostic studies for vascular assessment: Transcutaneous oxygen measurement (TCOM) Ankle brachial index (ABI) Arterial duplex scan Arteriogram Magnetic Resonance Arteriogram (MRA)
A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.
Chronic wounds may never heal or may take years to do so.
Encyclopedia
A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.
Chronic wounds may never heal or may take years to do so. These wounds cause patients severe emotional and physical stress as well as creating a significant financial burden on patients and the whole healthcare system.
Acute and chronic wounds are at opposite ends of a spectrum of wound healing types that progress toward being healed at different rates.
Epidemiology
Chronic wounds mostly affect people over the age of 60. The incidence is 0.78% of the population and the prevalence ranges from 0.18 to 0.32%. As the population ages, the number of chronic wounds is expected to rise.
Types
The vast majority of chronic wounds can be classified into three categories: venous ulcers, diabetic, and pressure ulcers. A small number of wounds that do not fall into these categories may be due to causes such as radiation poisoning or ischemia.
Venous ulcers
Venous ulcers, which usually occur in the legs, account for about 70% to 90% of chronic wounds and mostly affect the elderly. They are thought to be due to venous hypertension caused by improper function of valves that exist in the veins to prevent blood from flowing backward. Ischemia results from the dysfunction and, combined with reperfusion injury, causes the tissue damage that leads to the wounds.
Diabetic ulcers
Another major cause of chronic wounds, diabetes, is increasing in prevalence. Diabetics have a 15% higher risk for amputation than the general population due to chronic ulcers. Diabetes causes neuropathy, which inhibits nociception and the perception of pain. Thus patients may not initially notice small wounds to legs and feet, and may therefore fail to prevent infection or repeated injury. Further, diabetes causes immune compromise and damage to small blood vessels, preventing adequate oxygenation of tissue, which can cause chronic wounds. Pressure also plays a role in the formation of diabetic ulcers.
Pressure ulcers
Another leading type of chronic wounds is pressure ulcers, which usually occur in people with conditions such as paralysis that inhibit movement of body parts that are commonly subjected to pressure such as the heels, shoulder blades, and sacrum. Pressure ulcers are caused by ischemia that occurs when pressure on the tissue is greater than the pressure in capillaries, and thus restricts blood flow into the area. Muscle tissue, which needs more oxygen and nutrients than skin does, shows the worst effects from prolonged pressure. As in other chronic ulcers, reperfusion injury damages tissue.
Pain and chronic wounds
Chronic wound patients often report pain as dominant in their lives. It is recommended that healthcare providers handle the pain related to chronic wounds as one of the main priorities in chronic wound management (together with addressing the cause). Six out of ten venous leg ulcer patients experience pain with their ulcer, and similar trends are observed for other chronic wounds.
Persistent pain (at night, at rest, and with activity) is the main problem for patients with chronic ulcers. Frustrations regarding ineffective analgesics and plans of care that they were unable to adhere to were also identified.
Contributing factors
In addition to poor circulation, neuropathy, and difficulty moving, factors that contribute to chronic wounds include systemic illnesses, age, and repeated trauma. Comorbid ailments that may contribute to the formation of chronic wounds include vasculitis (an inflammation of blood vessels), immune suppression, pyoderma gangrenosum, and diseases that cause ischemia. Immune suppression can be caused by illnesses or medical drugs used over a long period, for example steroids. Emotional stress can also negatively affect the healing of a wound, possibly by raising blood pressure and levels of cortisol, which lowers immunity.
What appears to be a chronic wound may also be a malignancy; for example, cancerous tissue can grow until blood cannot reach the cells and the tissue becomes an ulcer. Cancer, especially squamous cell carcinoma, may also form as the result of chronic wounds, probably due to repetitive tissue damage that stimulates rapid cell proliferation. Another factor that may contribute to chronic wounds is old age. The skin of older people is more easily damaged, and older cells do not proliferate as fast and may not have an adequate response to stress in terms of gene upregulation of stress-related proteins. In older cells, stress response genes are overexpressed when the cell is not stressed, but when it is, the expression of these proteins is not upregulated by as much as in younger cells.
Comorbid factors that can lead to ischemia are especially likely to contribute to chronic wounds. Such factors include chronic fibrosis, atherosclerosis, edema, sickle cell disease, and arterial insufficiency-related illnesses.
Repeated physical trauma plays a role in chronic wound formation by continually initiating the inflammatory cascade. The trauma may occur by accident, for example when a leg is repeatedly bumped against a wheelchair rest, or it may be due to intentional acts. Heroin users who lose venous access may resort to 'skin popping', or injecting the drug subcutaneously, which is highly damaging to tissue and frequently leads to chronic ulcers. Children who are repeatedly seen for a wound that does not heal are sometimes found to be victims of a parent with Munchausen syndrome by proxy, a disease in which the abuser may repeatedly inflict harm on the child in order to receive attention.
Pathophysiology
Chronic wounds may affect only the epidermis and dermis, or they may affect tissues all the way to the fascia. They may be formed originally by the same things that cause acute ones, such as surgery or accidental trauma, or they may form as the result of systemic infection, vascular, immune, or nerve insufficiency, or comorbidities such as neoplasias or metabolic disorders. The reason a wound becomes chronic is that the body’s ability to deal with the damage is overwhelmed by factors such as repeated trauma, continued pressure, ischemia, or illness.
Though much progress has been accomplished in the study of chronic wounds lately, advances in the study of their healing have lagged behind expectations. This is partly because animal studies are difficult because animals do not get chronic wounds, since they usually have loose skin that quickly contracts, and they normally do not get old enough or have contributing diseases such as neuropathy or chronic debilitating illnesses. Nonetheless, current researchers now understand some of the major factors that lead to chronic wounds, among which are ischemia, reperfusion injury, and bacterial colonization.
Ischemia
Ischemia is an important factor in the formation and persistence of wounds, especially when it occurs repetitively (as it usually does) or when combined with a patient’s old age. Ischemia causes tissue to become inflamed and cells to release factors that attract neutrophils such as interleukins, chemokines, leukotrienes, and complement factors.
While they fight pathogens, neutrophils also release inflammatory cytokines and enzymes that damage cells. One of their important jobs is to produce ROS to kill bacteria, for which they use an enzyme called myeloperoxidase. The enzymes and ROS produced by neutrophils and other leukocytes damage cells and prevent cell proliferation and wound closure by damaging DNA, lipids, proteins, the ECM, and cytokines that speed healing. Neutrophils remain in chronic wounds for longer than they do in acute wounds, and contribute to the fact that chronic wounds have higher levels of inflammatory cytokines and ROS. Since wound fluid from chronic wounds has an excess of proteases and ROS, the fluid itself can inhibit healing by inhibiting cell growth and breaking down growth factors and proteins in the ECM.
Bacterial colonization
Since more oxygen in the wound environment allows white blood cells to produce ROS to kill bacteria, patients with inadequate tissue oxygenation, for example those who suffered hypothermia during surgery, are at higher risk for infection. The host’s immune response to the presence of bacteria prolongs inflammation, delays healing, and damages tissue. Infection can lead not only to chronic wounds but also to gangrene, loss of the infected limb, and death of the patient.
Like ischemia, bacterial colonization and infection damage tissue by causing a greater number of neutrophils to enter the wound site. In patients with chronic wounds, bacteria with resistances to antibiotics may have time to develop. In addition, patients that carry drug resistant bacterial strains such as methicillin-resistant Staphylococcus aureus (MRSA) have more chronic wounds.
Growth factors and proteolytic enzymes
Chronic wounds also differ in makeup from acute wounds in that their levels of proteolytic enzymes such as elastase. and matrix metalloproteinases (MMPs) are higher, while their concentrations of growth factors such as Platelet-derived growth factor and Keratinocyte Growth Factor are lower.
Since growth factors (GFs) are imperative in timely wound healing, inadequate GF levels may be an important factor in chronic wound formation. In chronic wounds, the formation and release of growth factors may be prevented, the factors may be sequestered and unable to perform their metabolic roles, or degraded in excess by cellular or bacterial proteases.
Chronic wounds such as diabetic and venous ulcers are also caused by a failure of fibroblasts to produce adequate ECM proteins and by keratinocytes to epithelialize the wound. Fibroblast gene expression is different in chronic wounds than in acute wounds.
Though all wounds require a certain level of elastase and proteases for proper healing, too high a concentration is damaging. Leukocytes in the wound area release elastase, which increases inflammation, destroys tissue, proteoglycans, and collagen, and damages growth factors, fibronectin, and factors that inhibit proteases. The activity of elastase is increased by human serum albumin, which is the most abundant protein found in chronic wounds. However, chronic wounds with inadequate albumin are especially unlikely to heal, so regulating the wound's levels of that protein may in the future prove helpful in healing chronic wounds.
Excess matrix metalloproteinases, which are released by leukocytes, may also cause wounds to become chronic. MMPs break down ECM molecules, growth factors, and protease inhibitors, and thus increase degradation while reducing construction, throwing the delicate compromise between production and degradation out of balance.
Treatment Though treatment of the different chronic wound types varies slightly, appropriate treatment seeks to address the problems at the root of chronic wounds, including ischemia, bacterial load, and imbalance of proteases. Various methods exist to ameliorate these problems, including antibiotic and antibacterial use, debridement, irrigation, vacuum-assisted closure, warming, oxygenation, moist wound healing, removing mechanical stress, and adding cells or other materials to secrete or enhance levels of healing factors.
Preventing and treating infection
To lower the bacterial count in wounds, therapists may use topical antibiotics, which kill bacteria and can also help by keeping the wound environment moist, which is important for speeding the healing of chronic wounds. Some researchers have experimented with the use of tea tree oil, an antibacterial agent which also has anti-inflammatory effects. Disinfectants are contraindicated because they damage tissues and delay wound contraction. Further, they are rendered ineffective by organic matter in wounds like blood and exudate and are thus not useful in open wounds.
A greater amount of exudate and necrotic tissue in a wound increases likelihood of infection by serving as a medium for bacterial growth away from the host’s defenses. Since bacteria thrive on dead tissue, wounds are often surgically debrided to remove the devitalized tissue. Debridement and drainage of wound fluid are an especially important part of the treatment for diabetic ulcers, which may create the need for amputation if infection gets out of control. Mechanical removal of bacteria and devitalized tissue is also the idea behind wound irrigation, which is accomplished using pulsed lavage.
Removing necrotic or devitalzed tissue is also the aim of maggot therapy, the intentional introduction by a health care practitioner of live, disinfected maggots non-healing wounds. Maggots dissolve only necrotic, infected tissue; disinfect the wound by killing bacteria; and stimulate wound healing. Maggot therapy has been shown to accelerate debridement of necrotic wounds and reduce the bacterial load of the wound, leading to earlier healing, reduced wound odor and less pain. The combination and interactions of these actions make maggots an extremely potent tool in chronic wound care.
Negative pressure wound therapy (NPWT) is a treatment that improves ischemic tissues and removes wound fluid used by bacteria. This therapy, also known as vacuum-assisted closure, reduces swelling in tissues, which brings more blood and nutrients to the area, as does the negative pressure itself. The treatment also decompresses tissues and alters the shape of cells, causes them to express different mRNAs and to proliferate and produce ECM molecules.
Treating painful wounds
Persistent chronic pain associated with non-healing wounds is caused by tissue (nociceptive) or nerve (neuropathic) damage and is influenced by dressing changes and chronic inflammation. Chronic wounds take long time to heal and patients can suffer from chronic wounds for many years . Chronic wound healing may be compromised by coexisting underlying conditions, such as venous valve backflow, peripheral vascular disease, uncontrolled edema and diabetes mellitus.
If wound pain is not assessed and documented it may be ignored and/or not addressed properly. It is important to remember that increased wound pain may be an indicator of wound complications that need treatment, and therefore practitioners must constantly reassess the wound as well as the associated pain.
Optimal management of wounds requires holistic assessment. Documentation of the patient’s pain experience is critical and may range from the use of a patient diary, (which should be patient driven), to recording pain entirely by the healthcare professional or caregiver. Effective communication between the patient and the healthcare team is fundamental to this holistic approach. The more frequently healthcare professionals’ measure pain, the greater the likelihood of introducing or changing pain management practices.
At present there are few local options for the treatment of persistent pain, whilst managing the exudate levels present in many chronic wounds. Important properties of such local options are that they provide an optimal wound healing environment, while providing a constant local low dose release of ibuprofen during weartime.
If local treatment does not provide adequate pain reduction, it may be necessary for patients with chronic painful wounds to be prescribed additional systemic treatment for the physical component of their pain. Clinicians should consult with their prescribing colleagues referring to the WHO pain relief ladder of systemic treatment options for guidance. For every pharmacological intervention there are possible benefits and adverse events that the prescribing clinician will need to consider in conjunction with the wound care treatment team.
Treating ischemia and hypoxia
Blood vessels constrict in tissue that becomes cold and dilate in warm tissue, altering blood flow to the area. Thus keeping the tissues warm is probably necessary to fight both infection and ischemia. Some healthcare professionals use ‘radiant bandages’ to keep the area warm, and care must be taken during surgery to prevent hypothermia, which increases rates of post-surgical infection.
Underlying ischemia may also be treated surgically by arterial revascularization, for example in diabetic ulcers, and patients with venous ulcers may undergo surgery to correct vein dysfunction.
Diabetics that are not candidates for surgery (and others) may also have their tissue oxygenation increased by Hyperbaric Oxygen Therapy, or HBOT, which can compensate for limitations of blood supply and correct hypoxia. In addition to killing bacteria, higher oxygen content in tissues speeds growth factor production, fibroblast growth, and angiogenesis. However, increased oxygen levels also means increased production of ROS. Antioxidants, molecules that can lose an electron to free radicals without themselves becoming radicals, can lower levels of oxidants in the body and have been used with some success in wound healing.
Low level laser therapy has been repeatedly shown to significantly reduce the size and severity of diabetic ulcers as well as other pressure ulcers.
Growth factors and hormones
Since chronic wounds underexpress growth factors necessary for healing tissue, chronic wound healing may be speeded by replacing or stimulating those factors and by preventing the excessive formation of proteases like elastase that break them down.
One way to increase growth factor concentrations in wounds is to apply the growth factors directly, though this takes many repetitions and requires large amounts of the factors. Another way is to spread onto the wound a gel of the patient’s own blood platelets, which then secrete growth factors such as vascular endothelial growth factor (VEGF), insulin-like growth factor 1–2 (IGF), PDGF, transforming growth factor-ß (TGF-ß), and epidermal growth factor (EGF). Other treatments include implanting cultured keratinocytes into the wound to reepithelialize it and culturing and implanting fibroblasts into wounds. Some patients are treated with artificial skin substitutes that have fibroblasts and keratinocytes in a matrix of collagen to replicate skin and release growth factors. In other cases, skin from cadavers is grafted onto wounds, providing a cover to keep out bacteria and preventing the buildup of too much granulation tissue, which can lead to excessive scarring. Though the allograft (skin transplanted from a member of the same species) is replaced by granulation tissue and is not actually incorporated into the healing wound, it encourages cellular proliferation and provides a structure for epithelial cells to crawl across. On the most difficult chronic wounds, allografts may not work, requiring skin grafts from elsewhere on the patient, which can cause pain and further stress on the patient’s system. Collagen dressings are another way to provide the matrix for cellular proliferation and migration, while also keeping the wound moist and absorbing exudate. Since levels of protease inhibitors are lowered in chronic wounds, some researchers are seeking ways to heal tissues by replacing these inhibitors in them. Secretory leukocyte protease inhibitor (SLPI), which inhibits not only proteases but also inflammation and microorganisms like viruses, bacteria, and fungi, may prove to be an effective treatment.
Research into hormones and wound healing has shown estrogen to speed wound healing in elderly humans and in animals that have had their ovaries removed, possibly by preventing excess neutrophils from entering the wound and releasing elastase. Thus the use of estrogen is a future possibility for treating chronic wounds.
Imago Care Ltd are a UK based company who procure the most effective products in the health care market to help redefine wound care best practice.
There are currently over 200,000 chronic wound cases which cost the UK over £1 billion each year. Hospitals and clinics continually search for the latest wound care technology to drive down costs by improving patient wound healing rates. Imago Care Ltd actively seek out these innovative products and solutions so that they can help chronic and acute wound patients heal quickly and as pain free as possible.
