Today's Wound Clinic - Winter 2008 - (Page 35) inpersective The Frustrating 15: What’s Missing? DOT WEIR, RN, CWON, CWS THE IMPACT OF BACTERIA Managing bacterial burden in venous ulceration can be challenging. Venous ulcers characteristically present with high exudate, inflammation, and pain. Clinicians may interpret these signs and symptoms as indications for culture and subsequent medical management, or conversely, dismiss them as unavoidably related to the presence of an ulcer and not requiring treatment. Recognizing the presence of true clinical infection in these patients may be difficult. Serena et al4 analyzed the data from a large multicenter clinical trial to determine the accuracy of clinical examination in diagnosing infection in venous leg ulcers.As part of the protocol, quantitative biopsies were performed as part of the screening process. Of 614 screening biopsies, 122 were found to have a colony count ≥106, indicating the presence of infection. Of the 352 patients eventually enrolled in the trial, 26% were found to have infected ulcers despite a lack of clinical symptoms. Gardner et al5 evaluated different types of wounds and found little correlation between wound bed infection and classic signs of infection. The signs that had positive predictive value were delayed wound healing over time, friability and discoloration of granulation tissue, pocketing at the base of the wound, foul odor, wound breakdown, and increased pain (see figure 1). These studies suggest that there is no substitute for a thorough clinical evaluation, consideration of the wound age at the time of presentation, and close observation of wound progress. A current trend is to use topical antimicrobials to reduce bioburden and then switch to some other topical management that does not injure healthy cells or encourage resistance. However, some patients require continued use of a topical antimicrobial agent, occasional oral antibiotics, and in a very rare case, long-term oral antibiotics until they are healed.The importance of clinical judgment cannot be over-emphasized when describing potential issues that may be occurring even with the wraps. Today’s Wound Clinic Winter 2008 C aroline Fifes’s commentary on the state of healing of venous leg ulcers over the years evoked several questions. She described the “frustrating 15%,” describing the relatively small change in healing rates of this population of patients through the years. This begs the question, how can this be? Our diagnostic skills regarding recognition of atypical ulcers that masquerade as venous ulcers have improved and we have many more advanced and “active” topical approaches in our treatment armamentarium. As Caroline more than adequately noted, wound care professionals know and understand the necessity of adequate compression and many sophisticated options for providing that compression are available. What is missing in the care of that frustrating population (the 15%) of refractory ulcers? Although the following ideas might not change outcome statistics, at least five factors must be understood in order to impact refractory ulcerations: 1. Patient participation 2. Recognition of the impact of bacteria 3. Recognition of atypical ulcers 4. Use of advanced treatments 5. Defining closure versus healing. PATIENT PARTICIPATION Chronic venous insufficiency (CVI) is a significant health problem in the US, accounting for 70% to 80% of the approximate 2.5 million people affected with lower extremity ulcers1,2 The impact on patients and their families, as well as on the healthcare system, are enormous — 5% of patients lose their jobs and 4.6 million US work days are missed each year as a result of venous disease.3 Patients unable to miss work must choose between a healed wound or keeping their job. Sometimes they are labeled “non-compliant” or “non-adherent” to treatment plans. Perhaps there are times when the plans need changing. This author is not advocating giving in to all patients who do not want to wear a wrap because their designer shoes won’t fit. A better phrase might be “occupationally non-compliant” — patients for whom adhering to treatment plans could result in the loss of the job that puts the food on their table and provides health insurance to reimburse care. To keep patients working, clinicians need to direct patients to compression wraps that accommodate shoes or to alter shoe wear to accommodate the wraps. It is crucial to work with patients to find solutions for these logistical problems. Most heavy boots (eg, construction boots) will still fit with certain two- and three-layer wraps. Narrow dress shoes often won’t fit so a post-op type of shoe may need to be provided. Teaching the patient or a family member to use a reusable wrap is an option, but one that may sacrifice the level of compression achieved. A patient may need to be fitted for successive pairs of compression garments, presenting a potential new set of problems regarding affordability and availability of sequentially smaller hose to promote the continued reduction in edema. Weekly patient appointments, generally the norm for changing wraps, also can pose work problems. Caregivers may be required to contact employers to explain the importance of clinic visits. Caregivers also can accommodate the patient by providing early or late appointments. There always will be patients unable or unwilling to comprehend the need for compression and the role that they play in their own healing — patients who continue to smoke, patients with diabetes who will not work toward blood glucose control, and patients who remove their wraps “just because.” However, these patients are the exception rather than the rule. 35
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