Treating Wounds—the Holistic Way
At a New York medical center, a new program aims to prevent small problems from getting out of control
http://online.wsj.com/article/SB10001424052702304023504577321404093450624.html
By LAURA LANDRO
Confined to a wheelchair with spina bifida, a
disease that causes damage to the spinal cord and a lifetime of
complications, 22-year-old Cyniya Daniels must constantly battle one of
the most daunting of the complications: chronic wounds from pressure
ulcers caused by her immobility.
But thanks to an innovative program at
Montefiore Medical Center in the Bronx borough of New York City, Ms.
Daniels's wounds are carefully monitored with a comprehensive approach
that includes preventive screening, early detection and aggressive
treatment, both from doctors and nurses at the center's wound clinic and
from medical staff who visit her at home.
Commonly known as bedsores, pressure ulcers can happen to vulnerable
and ill patients over an extended hospital stay. Wounds can also start
as a complication of diabetes, an ulcer from a problem leg vein or an
infection at the site of a surgical incision. But they can last for
months or years, and may never fully heal. And often, they are poorly
understood and insufficiently treated, studies show.
HELPING HEAL An oxygen chamber is used for wounds at Montefiore Medical Center in the Bronx.
While chronic wounds tend to affect
mostly unhealthy elderly, poor and disabled patients, especially those
confined to a wheelchair or bed, increasing numbers of obese Americans
are at risk, too. Extra pounds put more pressure on skin, and poor
nutrition and other issues impede healing. Painful, unsightly and
sometimes malodorous chronic wounds can lead to depression and social
isolation—and in many cases amputations.
Growing Problem
Pointing to an aging population, and the
sharp rise in diabetes and obesity, researchers at major wound-care
centers warned in a 2009 study in the journal Wound Repair and
Regeneration that chronic wounds are "a major and snowballing threat to
public health and the economy," costing upwards of $25 billion a year to
treat.
Over the past decade, more wound
clinics have popped up and new treatments have flooded the market, from
cultured skin cells that stimulate tissue to heal, to pumps that drain
wounds using a special sealed dressing. Hospitals are buying pressure
redistribution mattresses that keep the pressure off bedsores and foot
ulcers, and oxygen chambers that patients spend hours in to help heal
certain types of wounds.
To evaluate the cost-effectiveness and relative benefits of the
myriad products and procedures, the federal Agency for Healthcare
Research and Quality recently awarded a grant to the wound clinic at
Johns Hopkins Bayview Medical Center and the Johns Hopkins
Evidence-based Practice Center.
But Gerald Lazarus, founder of the Hopkins clinic and co-principal
investigator for the review, says the most promising approach to wound
care isn't any specific product or service, but rather a comprehensive,
holistic approach to care.
"The secret to success at a wound clinic is to deal with all of a
patient's issues, but a lot of clinics just focus on dealing with the
wound," Dr. Lazarus says.
Getting Ahead
Studies have shown that getting ahead of wounds before they become dangerous can dramatically improve outcomes.
A review of programs to prevent bedsores, or pressure ulcers,
published in the current issue of Skin and Wound Care, found that
following certain routines, including assessing patients for bedsore
risk, turning them frequently in hospital beds to redistribute pressure
on the skin, and monitoring skin for signs of a developing chronic
wounds, can help reduce their incidence and severity.
Such approaches have been known to be effective for years. But the
study notes that making them a routine part of care continues to be a
challenge for many institutions.
Montefiore's wound center offers the latest treatments such as oxygen
therapy and tissue regeneration. "We may reduce the need for more
expensive technologies by treating wounds earlier and better so they
have the best chance of healing," says Director Anna Flattau,
She was recently selected by the Centers for Medicare and Medicaid
Services to participate in an Innovation Advisors program, which is
testing new models of care delivery. Her approach coordinates care among
doctors, physician assistants and nurses to prevent wounds like
bedsores or diabetic foot ulcers before they develop, and aggressively
treat them if they do start. The aim is to improve the quality of care
while also reducing hospitalizations, emergency-room visits and total
costs.
Wounds must be surgically debrided to remove dead or infected tissue
or they may never heal. But according to Dr. Flattau, clinics often may
not perform debridement until a wound is advanced; infections that have
reached into the bone, too, are often diagnosed late or missed.
By contrast, she says, at Montefiore, the sickest patients are seen
more frequently, receive more aggressive debridement, and are more
closely monitored for wound infection. Montefiore trains residents in
wound care and prevention as well.
"Medical schools and residency programs typically have no or minimal
instruction in chronic-wound healing, and a lot of medical students
don't know how to turn a patient over in a hospital bed or examine them
for wound risks," she says.
Better Follow-Up
After hospital discharge, many patients are
lost to follow-up or have trouble making it to an outpatient wound
clinic, especially in urban locations such as Montefiore's. That led
Montefiore to create the pilot home-care follow-up program for patients
who are wheelchair-bound, live in walk-ups or have difficulty arranging
transportation to clinic appointments.
"A pressure-ulcer patient may start with a small, potentially easily
manageable wound that over months without care becomes an enormous
bedsore with underlying bone infection that causes the patient to become
septic," a potentially fatal blood poisoning, Dr. Flattau says. "The
usual health-care system, which may be hard to navigate even for a
relatively healthy person, is a potential disaster for these patients."
As part of the home-care program, family caregivers are taught to
deal with issues that can arise. Ms. Daniels, the spina bifida patient,
says she and her mother were trained to use equipment such as special
cushions and a sliding board that helps Ms. Daniels get from bed to her
motorized wheelchair.
A nurse comes once a week to help clean her wounds, discuss
medications and maintenance strategies, and generally offer support.
Though she has had to be hospitalized on several occasions when her
wounds got infected, she feels the Montefiore program, especially the
home-care nursing, has helped her get them under control.
"Whenever I have questions or concerns, they are there and give me
all kinds of tips to prevent bad things from happening," she says. "You
have to deal with what life gives you, but I am very happy knowing I
have help to deal with this."
Ms. Landro is an assistant managing editor for The
Wall Street Journal and writes the paper's Informed Patient column. She
can be reached at
laura.landro@wsj.com.
A version of this article appeared April 16,
2012, on page R9 in some U.S. editions of The Wall Street Journal, with
the headline: Treating Wounds—the Holistic Way.
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