November is family caregiver recognition month in the US.1 This is an ideal time to reflect on skin and wound care challenges faced by our patients and their families. Implementation of the Caregiver Advise Record Enable (CARE) Act has resulted in an urgent call for professionals to facilitate care through enhanced communication and patient/caregiver education. We need to use this opportunity to develop new ways to partner with our patients and their families, especially when wounds are not healing at the expected rate.2-4
This month's CE/CME article provides a framework or supporting structure to systematically review and optimize care for persons with nonhealing wounds. This framework could evolve into a useful checklist if the items are validated as compulsory criteria to establish a healing trajectory. The components of the framework can be divided into the Wound Bed Preparation model, including patient-centered concerns along with the treatment of the cause, ability to heal, and local wound care.5
Patient-centered concerns revolve around pain, activities of daily living, and the patients' circle of care. If pain is categorized on an 11-point numerical rating scale (0-10, where 0 is no pain), most patients can live with a pain level of 3 or 4 and carry out activities of daily living. Wound care providers need to take coresponsibility for care negotiated with the patient and his or her circle of care. For example, patients with pain should be offered options for treating both nociceptive and neuropathic pain with adjustable medications and diversional therapies. An adequate support network can facilitate attendance at healthcare appointments, good nutrition, adherence to treatment, and a clean home environment.
Most wound care professionals agree that persons with chronic wounds can present with a variety of comorbidities and factors that can impact on wound healing. The complexity of these cases requires care coordination and communication to facilitate a mutually agreeable plan of care. Wounds that are not in a healing trajectory especially require a comprehensive assessment (ideally with an interprofessional team) to establish a precise diagnosis and identify modifying factors that may or may not be correctable.6 These assessments should involve the "whole patient" and not only the "hole in the patient!"
In addition to vascular function, the CE/CME discusses a number of other variables that can delay healing:
* Suboptimal nutrition corrected with dietary counseling and healthy eating
* Smoking tobacco with counseling to reduce or stop
* Inadequate diabetes control optimized with hemoglobin A1c as close to 7 as possible
* Abnormal laboratory studies (low hemoglobin, impaired liver and kidney function)
* Other coexisting diseases (rheumatoid arthritis, malignancy) or drugs (steroids, immunosuppressive agents) that can impair healing
* Clinical signs of infection that need to be treated with antimicrobial therapy
Outlining key factors to consider facilitates interprofessional team communication and ultimately potentially enhances treatment. Ideally, we can heal most wounds with a framework for improved diagnosis, identification of modifiable factors, and evaluation of patient response to the treatment. The quality of life can also be improved for patients with nonhealable wounds by addressing patient-centered concerns and concentrating on the needs of the whole person.
R. Gary Sibbald, BSc, MD, DSc (Hons), MEd, FRCPC (Med Derm), FAAD, MAPWCA, JM
Elizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN
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