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.