Drexel Hill, Pa. – Six million people in the United States live with chronic wounds on their legs and feet, a painful, debilitating condition that damages quality of life and often leads to amputation.  Their situation is often complicated by more immediate health challenges, and sometimes, a lack of awareness among caregivers that many new wound therapies are available. 

Recently, a team led by Stephen L. Harlin, M.D., a plastic and reconstructive surgeon at Delaware County Memorial Hospital (DCMH) and clinical assistant professor at Drexel University College of Medicine, set out to create the first peer-reviewed performance measurement standard for the care of chronic wounds of the lower extremities.  “Our work attempted to identify a subset of clinical practices widely accepted as beneficial to all patients with non-healing wounds,” Harlin says.

The resulting paper*, published in the January 2008 Plastic and Reconstructive Surgery Journal, is quickly becoming a benchmark reference for caregivers and medical regulatory groups across the nation as they seek to advance and standardize chronic wound care to prevent morbidity and mortality. 

Chronic Wounds Take a “Village” of Expertise

Principally written by Harlin, the paper represents two years of work by 16 colleagues from across the health spectrum, many of them from DCMH.  It is directed toward health care practitioners who manage the ongoing care of patients with chronic wounds of the lower extremities.  This includes primary care physicians, who are often the first to encounter chronic wounds as they care for a growing number of elderly and diabetic patients, those most vulnerable to the condition, as well as home health providers and inpatient staff.   “Many health care professionals provide basic and high-quality wound care and witness prompt and uncomplicated healing,” says Harlin.  “For patients whose wounds fail to heal in a reasonable time or pose grave threat, timely referral to a wound care specialist should be considered.”

Treating non-healing wounds is particularly difficult, Harlin says, because “patients with chronic wounds represent a widely diverse population…no two chronic wounds are the same.  Second, the literature on wound care is often biased and clinical trials frequently lack statistical power.  Lastly, standards are changing rapidly as scientific knowledge and technology advance.

“Fundamentally, chronic wounds of the lower extremity are treated with a protocol emphasizing surgical debridement – removal of diseased tissue, pressure relief, infection control, and management of wound drainage.  For high-risk and recalcitrant wounds, reconstructive plastic surgery and adjunctive therapies may also play a role,” he says.

Wounds May Not Be First Concern

Many times in primary care appointments, attention for chronic wounds is crowded out by more pressing conditions, explains Joan C. Waller, M.D., a DCMH infectious disease specialist who was part of the wound care work group. “These wounds impair patients’ quality of life in a low-grade way,” she says.  “They’re not the most important problem an elderly person has if he or she also has diabetes or high blood pressure.  A wound that’s been there for six months and isn’t getting any better or any worse isn’t the first thing they’re going to deal with.” 

Non-healing wounds can also be complicated to manage, requiring the coordination of numerous medical specialties.  “First and foremost, a breach in the integrity of skin impairs the body’s first line of defense against infection,” Harlin says.  “Proper care involves many subspecialists.  Surgeons remove diseased wound tissue and obtain biopsies, and because the foot is often involved, podiatric surgeons face complicated management issues.  Infectious disease experts help guide the choice and duration of antibiotic therapy for what is often a virulent subset of microorganisms.  Wounds and/or their treatment can interfere with mobility, so physical therapists such as Veronica Hache, PT-WCC at DCMH can be critical to preserving function while protecting from excess pressure and shear.” Nutritionists are essential to ensure that patients get enough protein, which is essential for healing and can be depleted through wound drainage. 

Harlin hastens to note the role specially certified nurses such as Maureen Ingram, RN-C, MSN, CWOCN of DCMH:  “The really laborious and time-consuming work of wound care – dressing care, irrigations, preventive measures, patient education – is done by the wound care nurse.  Maureen does an absolutely extraordinary job.”

Work Becoming National Reference

In addition to its journal exposure, the work group’s recommendations have become the official

standard for chronic wound care for the American Society of Plastic Surgeons Health Policy Committee.  These guidelines are used by the American Medical Association in developing quality measures for the Centers of Medicare and Medicaid Services.

“As lead author and chair of the work group, my objective was to conduct a systematic review of all scientific literature and to develop recommendations that fairly reflect current accepted medical standards,” Harlin says.  “I was greatly impressed by the level of knowledge and experience demonstrated by my colleagues…Physicians in the Crozer-Keystone system are leading the way to safeguard high standards in the clinical practice of wound care – developing new educational tools to help practitioners make smart decisions, translate research into practice, and simplify clinical wound care.” 

In addition to Harlin and Waller, members of the work group affiliated with DCMH include: internist and geriatrician Joseph C. Goldschmidt, M.D., Ph.D.; podiatric surgeon Bruce G. Greenfield, D.P.M.; physical therapist Veronica E. Hache, PT-WCC; surgeon Seth A. Malin, M.D.; surgeon Lawrence J. Mayer, M.D.; interventional radiologist Rajit R. Shah, M.D.; and podiatric surgeon Andrew T. Teplica, D.P.M.    

Healing, Even When No Cure Is Possible

“This is a beautifully researched seminal article,” says Waller.  “There is now an extensive body of information out there that we can restore 70, 75, even 90-year-olds to better comfort and better health.  It is important for primary doctors to know that specialty wound care centers have new and exciting ways to treat wounds.  People can be cured – it is not something they have to live with.”

Even when chronic wounds cannot be cured, Harlin says, care matters.  “One of the most important aspects of medicine comes from the practitioner’s healing presence.  For there is  healing in simply being with the patient, listening, showing interest and support, asking questions.  For some patients, there may be no pharmacological nor surgical cure for their wound.  In this relationship, compassion and a sense of shared humanity may be the best that can be practiced.”

Delaware County Memorial Hospital is a member of the Crozer-Keystone Health System. We’re 5 hospitals, 2,600 doctors and nurses, and 7,100 caring people with 1 vision. Crozer-Keystone. Something to feel good about.