Published in the June 2008 issue of Today’s Hospitalist
Given the aging population, the growing number of problematic wounds and the rise of multi-drug resistant infections, taking care of patients with wounds can no longer be considered a no-brainer “or passed off to other staff.
Historically, “wound care was looked at as a nursing issue, but that attitude has changed,” said Gerit Mulder, DPM, MS, associate professor of surgery and orthopedics and director of the wound treatment and research center at the University of California, San Diego. “The doctor is ultimately responsible for the orders given to care for wounds.”
Substandard, inappropriate or incorrect wound care is a major reason why families sue doctors and hospitals, alleging malpractice. And botched wound care is one therapy that Medicare and other payers are moving to not pay for, contending that problems with pressure ulcers and associated resistant infections, for instance, occur primarily because of poor quality of care.
Dr. Mulder said this means hospitalists need to get up to speed on wound management skills. They also need, he added, to improve communication and education for patients and families related to wound-healing expectations and provide better documentation in the medical record.
“Not all wounds can be prevented and not all can be healed,” he told hospitalists during a session at the Society of Hospital Medicine annual meeting this spring. “You need to put the probability of healing in the record.” It’s time to get up to speed on wound c
The time has come, said Dr. Mulder, when patients being admitted will be tested for colonization with infections like MRSA. A hospital needs to document that the 92-year-old patient admitted from a nursing home with an infected pressure ulcer had a pre-existing problem. Hospitals also need to determine and document at admission the presence of resistant organisms.
To minimize liability, Dr. Mulder said, spend time educating patients and families that many factors including poor nutritional status, low protein levels or impaired vascular flow may put patients at high risk for never completely healing. “Document that educational process in the chart,” he said.
In addition, Dr. Mulder said to plan on having some tough conversations. “You have to let patients know that if the wound is venous and they won’t wear compression, we may not be able to heal it,” he said. “If they smoke, I tell them they may not heal because of the effects of cigarettes. And if they are obese, I tell them that until they lose weight, the best I can do “in cases of lower extremity ulcers associated with venous disease and lymphedema “is to try to keep it from getting worse. You have to give patients realistic expectations and tell them where they stand.”
Considering the litigation risks, hospitalists should be familiar with the current standards of care. The Wound Healing Society has collected its most recent guidelines in a special “Wound Repair and Regeneration” journal issue that is available free online ( HYPERLINK "http://www.blackwell-synergy.com/toc/wrr/14/6" www.blackwell-synergy.com/toc/wrr/14/6). Dr. Mulder suggested that hospitalists spend time reading through the guidelines on pressure ulcers, lower extremity arterial ulcers, venous ulcers and diabetic ulcers.
Dr. Mulder also offered the following wound care advice:
● Understand the underlying pathology. An important job for hospitalists is to ensure that the diagnosis of wound etiology and underlying pathology is correct.
“The biggest problem I see with lower extremity ulcers is everything on the leg being called a venous ulcer, simply because it is between the knee and the foot,” Dr. Mulder said. “You have to know the etiology to treat it.”
● Infection or colonization? Treating wound infections is different than treating other infections, Dr. Mulder pointed out. Not only may your choice of antibiotic differ, but you need to “differentiate between contamination, colonization and infection” before choosing treatment.
Redness, erythema and increased skin temperature “are secondary and not primary signs of infections because they can be associated with problems other than infection alone,” he explained. Treating non-infected wounds with antibiotics as a precaution “has not been proven to accelerate healing and may lead to resistance.”
For heavy topical colonization but no surrounding skin infection, he said, consider using a topical antimicrobial.
And before you document that a wound is infected, be sure there is an actual infection. Language counts, both clinically and in terms of litigation. “If you diagnose a true infection, you are obligated to treat with an antibiotic, either oral or IV,” said Dr. Mulder. “Be cautious about treating it with only a topical if you have called it an infection in the chart.”
● Cultures and dressing. Try not to change post-surgical wounds too frequently unless there is significant drainage because you increase the risk of introducing bacteria, Dr. Mulder said.
Nor is there any reason to routinely culture uninfected wounds, he added. A swab culture by itself won’t tell you if a wound is infected; instead, it indicates only what pathogens are present and whether the right antibiotic has been prescribed.
If you need a culture, he said, take a tissue specimen when possible. If swabbing is not contraindicated, aggressively debride then cleanse the wound before taking the swab.
● Choosing an antibiotic. Assume that most superficial, uncomplicated wounds will have predominantly gram-positive organisms. Start patients on a gram positive agent, then taper antibiotics based on response and culture results. Be aware of any past history of infections, particularly MRSA or resistant infections, and consider patients’ previous antibiotic response.
These patients generally can be put on oral antibiotics and sent home. But if they are at high risk for rapid deterioration, they may need to be admitted to makesure they respond to the antibiotic.
Patients with deep complicated wounds, on the other hand, usually need to be admitted. “We are seeing a lot of MRSA, a lot of multi-drug resistant pseudomonas and other resistant organisms that may lead to rapid tissue breakdown,” said Dr. Mulder.
Long courses of antibiotics for wound infections may not be justified, and antibiotics can be stopped “when the clinical signs and symptoms are gone,” he said. Debriding necrotic tissue is also important to remove biofilm and bacteria not eradicated by antibiotics.
Deborah Gesensway is a freelance writer reporting on U.S. health care from Toronto, Canada.