Non-pressure sore wounds: the Wound Care Center approach.

Freestanding wound care centers are starting to develop and are using new modalities for wounds of all types. Here is a report from one

These days, the prevention and treatment of pressure ulcers in the nursing home receives a great deal of attention in the literature, at professional meetings, and especially during daily rounds. However, much less attention is paid to non-pressure sore-type wounds. While not as prevalent among the nursing home population as decubiti, the fact is that ischemic, diabetic, and venous insufficiency ulcers can lead to equally, if not more, serious consequences: repeated hospitalizations, recalcitrant infection, and chronic antibiotic use, and even amputation. Unfortunately, treatment alternatives are limited and few long-term care facilities are equipped to deal adequately with these difficult wounds.

The solution to the problem is comprehensive, coordinated care that keeps wounds from deteriorating and becoming infected, and averts the need for hospitalization, repeated painful debridement, and amputation.

This accounts for the recent development of facilities, such as the Grant Wound Care Center in Columbus, Ohio, that are equipped to do just that. By treating nursing home residents on an outpatient basis, the center initiates and coordinates wound care and provides the nursing home with the expertise needed to continue that care, hopefully without the need for hospitalization.

These difficult wounds fall into three main categories. Ischemic ulcers are usually secondary to peripheral vascular disease. Patients present with a "cold" lower extremity, pain on walking (claudication) or, in later stages, pain at rest. These are the patients who report the need to get out of bed and walk during the night to restore circulation. The treatment of choice for ischemic ulcers is surgical revascularization, because the ulcers don't improve until blood flow to the extremity is restored. Diabetic ulcers also primarily affect the lower extremities. While they may develop whether or not the patient's hyperglycemia is under control, poorly controlled diabetics develop more problems with ulceration than do those who are well-controlled. Patients may have a lack of sensation in the effected extremity, which makes them extremely susceptible to injury. Some patients have been known to step on sharp objects and even literally walk a hole into the foot without knowing it.

These wounds may have an ischemic component as well. Thus, in addition to disease in large arteries which is generally treatable with surgery, they may also have ischemia in very small end arteries which are much less amenable to treatment.

The associated problems of diabetes, such as renal failure and blindness, almost always complicate treatment and delay healing. Unfortunately, the treatment options are limited and management often consists simply of preventing infection with debridement, topical antibiotics, and sometimes amputation.

Venous insufficiency (venous stasis) ulcers develop when veins in the lower extremities develop incompetent valves. Blood pools in the foot and calf, causing significant swelling and weeping wounds that ulcerate and form sores. Venous stasis ulcers affect a range of people: patients with a history of thrombophlebitis, women who develop incompetent veins after multiple child births, the patient whose occupation required long periods of standing, or even the wheelchair-bound patient whose feet are kept in a dependent position for extended periods of time.

Venous stasis ulcers are treated with elevation and compression, a treatment that is especially difficult in the wheelchair-bound resident unable to keep the feet elevated.

The key to managing these ulcers successfully is to treat the underlying disease as well as the wound itself. This requires a comprehensive program that includes sound communication between the medical director and nursing staff, the primary care physician and the wound care team -- the rationale for the wound care center.

One of the newer facets of such programs is the therapeutic use of growth factors. Growth factor is made with the patient's own platelets. The only commercially available growth factor to date, Procuren, is actually a combination of several platelet-derived wound healing factors.

The blood is drawn and then goes through a process of freezing and extraction and is ready for use in days. The substance is kept frozen between uses and is simply put onto a dressing and applied to the wound once daily until epithelial closure is achieved. The treatment is as simple as applying a saline dressing and is easily performed by a nursing assistant. The staff of the Grant Wound Care Center regularly instructs patients and family members, as well, in its use.

A number of growth factors have been used investigationally for over 3 years. The results of Grant's 4-month experience in 65 patients are comparable to those obtained in the national trials, which reported that most wounds treated with growth factor healed within 8 to 12 weeks.

Among specific results: For the ischemic ulcer, growth factor has been used to promote wound healing after revascularization. Growth factor has been especially successful in preventing further amputation in patients with diabetic ulcers. To date, it is indicated primarily in those ulcers in which exposed bone, tendon, or joints increase the risk of amputation.

Statistics indicate that half of patients who undergo an amputation will require still further amputation. For example, with most of the patient's weight concentrated on a remaining foot, the truncated extremity quickly develops the same problem that required initial amputation. Unless the wound heals, antibiotics will eventually fail, infection will develop, and further amputation will become inevitable. However, when growth factor is used to cover the wound and promote healing, a skin graft can be performed or the wound can be permitted to epithelialize naturally. This eliminates the risk of infection, sepsis, and further amputation.

In venous stasis ulcers, growth factor has been used to help speed healing after underlying disease has been treated with elevation and compression. However, three year follow-up results have not as yet established a significant advantage for growth factor over surgery or simple elevation and compression. It does appear, however, that growth factor used in conjunction with consistent elevation will produce significant healing, and more promising data may be forthcoming.

Growth factors are contraindicated in a few patients - for example, in cancer patients because of the theoretical possibility of stimulating growth of cancer cells, and possibly in patients with rare platelet bleeding disorders.

Even though Medicare still considers treatment with growth factor investigational, 80% of private insurance companies are reimbursing for its use. Clearly, it has a role in modern wound management, but must be optimized by a comprehensive approach, such as that offered by a specialized center.

Jeremy Burdge, M.D. is Medical Director of the Grant Wound Care Center, Columbus, Ohio.