HEQ speaks to the Association for the Advancement of Wound Care about infection control and innovation in wound treatment.
The Association for the Advancement of Wound Care (AAWC) is a multi-disciplinary non-profit organisation aimed at improving the clinical care of wounds across the USA.
What is the role of the AAWC within the broader healthcare sector?
The Association for the Advancement of Wound Care is the largest multi-disciplinary professional wound organisation in the United States. We influence wound care delivered by a wide variety of healthcare providers, from nurses to physical therapists to surgeons, and across all healthcare settings. Our members practise in academic universities, medical centres and acute care hospitals of all sizes, long-term care facilities, wound care centres and the community.
The diversity of our membership allows us to hear a broad range of voices on issues affecting wound care throughout healthcare. This informs our strategic plan and our education efforts. As leaders in wound care, we also partner with other organisations to assess, develop, and influence public policy related to wound care. Our goals are to improve wound care for the people who suffer with wounds and to support the healthcare providers who provide wound care.
The AAWC is keenly aware of the absence of a standardised and formal wound care curriculum within the clinical training programmes for physicians, advanced practice providers, nurses and physical therapists. This gap is one of the biggest hurdles to standardising and ultimately elevating the quality of the delivery of patient care.
The absence of formalised training results in a broad variation of clinical practice habits that can unfavourably impact clinical outcomes. The AAWC plays a vital leadership role in elevating the standard of care within the wound care space by providing evidence based educational opportunities to individuals who deliver direct patient care, administrative decision makers and those involved in the development of wound care health policies.
Are there preventive or protective lifestyle measures which patients can take to lower their risk of incurring complex wounds?
The most important lifestyle measure that people can take to lower their risk of developing chronic wounds is to move! Movement and activity are essential for maintaining skin and tissue health. Being active and walking are lifestyle choices that not only improve physical health but also mental health. Healthy nutrition is also important in lowering risk for chronic wounds. Eating a diet that is low in fat and that includes fruits and vegetables along with lean proteins is beneficial in maintaining a healthy weight.
Cessation of smoking or use of tobacco products is recommended to prevent problems with blood flow and tissue perfusion. For people who have diabetes, controlling blood glucose levels and checking their feet daily for any redness or open areas are critical in lowering their risk for chronic wound development. For persons with chronic venous insufficiency, wearing compression stockings/garments is essential to prevent venous leg ulcers.
Has the COVID-19 pandemic accelerated uptake of remote digital consultations for the ongoing treatment of wounds? Do you think telehealth will continue to be a priority once lockdowns are eased?
The COVID-19 pandemic has without a doubt accelerated the uptake of digital consultations for the ongoing treatment of wounds. The majority of hospital outpatient department (HOPD) wound clinics either adopted or expanded pre-existing telehealth services. Even innovative standalone private clinics adopted telehealth services to provide medical services to wound patients who were wary of coming into clinic.
Now that the telehealth infrastructure is in place, there is no doubt that wound care as a speciality will continue to leverage this useful technology. A good example would be at Intermountain Healthcare. Through a collaboration between Wound and Homecare teams, telehealth consultations in the patient’s home using a secure portal on the Homecare nurses’ iPhones was initiated and this tool will continue to be used. Patients who were targeted for the telehealth programme included those with non-progressing wounds, wounds requiring daily dressing changes, or significant challenges in transporting to a wound clinic. One of the particular benefits of this remote collaboration was the observation that patient compliance improved after the telehealth clinician reinforced the nurses’ instructions.
This example, as well as those of other existing telehealth programmes, affords many patients suffering with chronic wounds access to experts that would otherwise be unavailable. These services are especially valued in rural or critical access areas, and as such, fulfil a real need for patients with wounds who struggle with limited access to wound related healthcare.
It is clear that telehealth and telewound health will continue to be useful tools even after the pandemic lockdown is eased. Telehealth allows many patients access to specialists and experts that would otherwise be unavailable. These services are important in rural areas and in underserved areas and as such, they fulfil a real need for patients with wounds.
What are the main challenges facing wound care professionals in averting the risk of infection?
Wound care professionals have traditionally been diligent in using the appropriate precautions (universal, contact, airborne) when treating patients with wounds due to the possible exposure to body fluids. However, detecting critical colonisation or infection in wounds has relied upon observing clinical signs and symptoms, and in many cases only confirming with swab cultures. This approach has two critical consequences: the misuse and overuse of antimicrobial agents and systemic antibiotics, and the failure to detect significant bacterial loads in chronic wounds. A multi-centre controlled study of 350 wounds by Le et al found that 82% of the wounds had bacterial loads greater than 104 CFU/g (confirmed by tissue biopsy), and clinical signs and symptoms were not sufficient to detect infection in 85% of these cases. The use of fluorescence imaging was four times more accurate in detecting bacteria load as compared to clinical signs and symptoms1.
As a result of these findings, and the challenge of detecting and treating increasing numbers of antibiotic-resistant bacteria, hospitals and wound care clinics are mandated to adopt antimicrobial stewardship programmes (ASPs) with the goals of improving accuracy in the detection of type and amounts of bacteria in chronic wounds; initiating appropriate treatment for critical colonisation in a more timely manner, including debridement and use of topical antimicrobial agents; preventing the progression from colonisation to tissue infection, and guiding the use of antibiotics with more discrimination2.
One of the key components of the ASP is to incorporate fluorescence imaging into the standard of care for all chronic wounds. The fluorescence imaging device emits violet light at 405nm, causing porphyrin-producing bacteria (such as S. aureus to fluoresce red; Pseudomonas aeruginosa, cyan; and tissue, green. The most common pathogens seen in chronic wounds (gram positive, gram negative, aerobes, and anaerobes) will fluoresce red, and notably, bacteria in biofilm will also be detected3. This information can then be used to more efficaciously cleanse and debride wounds, appropriately use antimicrobial agents and antibiotics, and ultimately improve wound healing in a more timely and cost effective manner.
Can you give me some examples of good practice in clinical infection prevention protocols?
The one thing this pandemic has firmly implanted into the routines of most people is the importance of good hand hygiene. That in itself is a fundamental principle for infection prevention. Wound cleansing is ever-important, and commercial wound cleansers can be used to facilitate removal of contaminants. When changing a wound dressing it is critical to change gloves after removing the contaminated dirty dressings and don clean gloves to apply the new dressing. Furthermore, the technique used to apply the dressing should be a ‘no touch’ technique such that there is no touching of the surface of the dressing that will be contacting the wound surface.
The patient population within the speciality of wound care tends to be at a higher risk for complicating infections, given the fact that patients suffering with chronic ulcers are inclined to have multiple health-related comorbidities. In fact, an individual who has a diabetic foot ulcer (DFU) persisting for greater than 30 days is 4.7 times more likely to develop a wound related infection than a person with diabetes who has a DFU that is less than 30 days old. What complicates this scenario further is that people who develop a foot infection associated with a DFU present for more than 30 days are 55.7 times more likely to be hospitalised and 154.5 times more likely to undergo an amputation4.
Preventive measures that can be taken to help protect at-risk patients from developing life-threating infections include basic protocols, such as disinfecting treatment rooms between patient visits and preventing the spread of multi-drug resistant organisms to other patients by requiring medical staff to don the appropriate personal protective equipment when contact precaution measures are indicated. In the era of the COVID-19 pandemic, good practices in clinical infection prevention protocols have been critical in mitigating the transmission of SARS-CoV-2. A few of these protocols include:
- Allow patients to wait in a personal vehicle or outside the healthcare facility until they are contacted by mobile phone when it is their turn to be evaluated
- Schedule only one patient per appointment time. Minimise overlapping of patients in the clinic
- Implement social distancing of patients if clinic space allows. Physically separate available seating
- Initiate home health or telehealth services for wound care follow up where physical debridement may not be required during the visit
- Le L, Baer M, Briggs P, et al. Diagnostic accuracy of point-of-care fluorescence imaging for the detection of bacterial burden in wounds: Results from the 350-patient fluorescence imaging assessment and guidance trial. Advances in Skin and Wound Care, 2020. DOI: 10.1089/wound.2020.1272.
- Serena TE. Incorporating point-of-care bacterial fluorescence into a wound clinic Antimicrobial Stewardship Program. Diagnostics. 2020;10:1010. DOI: 10.3390/diagnostics10121010.
- Rennie MY, Dunham D, Lindvere-Teen L, et al. Understanding real-time fluorescence signals from bacteria and wound tissues observed with the MolecuLight i:X™. Diagnostics. 2019;9:22.
- Lavery LA, et al. Diabetes Care. 2006;29(6):1288-1293.
The following individuals contributed to these comments on behalf of the Association for the Advancement of Wound Care (AAWC):
Barbara Bates-Jensen, PhD, RN, FAAWC, AAWC President Elect
Karen L Bauer, DNP, APRN-FNP, CWS, FAAWC, AAWC Nurse Board Member
Ruth A Bryant, PhD, RN, CWOCN, FAAWC, AAWC President
Rose Hamm, PT, DPT, AAWC Physical Therapist Board Member
William Tettelbach, MD, FACP, FIDSA, FUHM, CWS, AAWC Physician Board Member