Filling wound care gaps

A person asks, pointing to an openly bleeding cut on the arm: “Which bandage is best for this wound?” Another person says: “I was in Emerg two days ago and they bandaged me up and told me to keep it dry. The bandage has now fallen off. Is this healing the way it should be? It’s quite red and painful. Do I need to go back to Emerg?” Many pharmacists can relate to the angst that one feels when asked these kinds of questions in a community pharmacy. Wounds can be acute or chronic, healing, non-healing or non-heal- able, and may or may not be complicated by co-existing medical conditions. Many wounds are healable if their cause can be treated, if there is adequate blood flow and if risk factors that hinder healing can be addressed. On the other hand, wounds in people with multiple comorbidities, immuno- compromised conditions and/or with foreign bodies can be com- plicated and hard to heal and can result in severe health outcomes, including infection, hospitalization and even death. In Ontario alone, wound care costs the healthcare system $1.5 billion annually, and statistically, every four hours, a person with diabetes will have a lower limb amputation due to a diabetic foot ulcer.1 Although pharmacists have not generally been recognized as key players on the wound care team, the current state of our healthcare system and the identified gaps in the management and prevention of wounds indicate that there could be significant benefits to improving access to care and community health outcomes by expanding the role of the pharmacist on the wound care team. Wound management and prevention can be challenging. With their high accessibility, pharmacists are often asked to do an impromptu wound assessment in their practices. In doing so, pharmacists must use their knowledge and clinical judgement to make recommendations, with the realization that their decisions could have wide-ranging consequences, from tremendous benefit to possible dire outcomes, such as amputation or even death. WOUND PREVENTION AND MANAGEMENT Figure 1 depicts the wound prevention and management cycle infographic from the Wounds Canada Best Practice Recommendations.2 It illustrates the five cyclical and continuous domains of care that support a person’s wound prevention and management journey. Certain aspects of three of these domains are particularly relevant for pharmacists, as outlined below. 1. ASSESS AND/OR REASSESS Perhaps one of the most difficult decisions for a pharmacist to make is determining whether you are comfortable being directly involved in the management of a person’s wound or whether referral to another healthcare professional is indicated. If you choose to refer the person, you need to be aware of your local community wound care resources in order to facilitate care. It also falls on the professional judgment of the pharmacist to assess the timeliness of the referral and where to refer based on the level of care required. For example, how quickly can this person be seen by their primary care provider and is the wound/person stable enough to wait until that time? Alternatively, has your assessment deter- mined that the wound requires more urgent care and/or specialized care and referral to the local hospital emergency department? During the determination of whether to engage in the direct management of a wound, the pharmacist must identify whether the person has any co-morbidities and/or factors that impair wound healing. Examples include diabetes mellitus with high glycemic parameters, advanced age, peripheral arterial disease, obesity, collagen vascular diseases (e.g., lupus, scleroderma, dermatomyositis), organ transplants, cancer, chemotherapy and therapeutic radiation. Table 1 summarizes factors associated with an increased risk of wound infection and poor wound healing.2 There is no definitive formula to determine the complexity of a wound and the risk of rapid wound deterioration; therefore, much is left to the pharmacist’s clinical skills and acumen. When it is unclear whether the wound or personal characteristics dictate a referral to another healthcare provider, pharmacists may choose to engage the patient and/or the caregiver in shared decision-making. For example, in my practice, I inform the person of the issues that impact their wound healing and ascertain the accessibility of other wound care healthcare team members (e.g., a primary care provider). Then I determine, together with the individual/caregiver, whether I should be actively involved in the management of the current wound. When I engage in direct care and the wound or personal characteristics are somewhat complex, I offer care provided that the individual or caregiver agrees to stay in close contact with me, and only after ensuring that the person or their caregiver has the capacity for this level of self-care. Assessment is a key component of wound care management because it allows the healthcare provider to identify the cause and risk severity of the wound. This is the basis upon which realistic goals are set, and a plan of care is established and then implemented. “It is important to remember that you are not treating the hole in the person but the whole person” (author unknown). 2. SET GOALS Prevention One of the ways I practise wound prevention is by identifying people with, or at risk of, lower leg edema. Edema increases vascular tension and reduces blood flow; compromised vascularized tissues are at risk of poor wound healing due to the inability to deliver oxygen, nutrients and antibiotics to the tissues and/or clear waste products from the site of the wound. People at risk of lower leg edema include those who are overweight or obese, or have congestive heart failure or chronic kidney disease, people who don’t walk or have compromised walking with impaired calf-muscle pump activation (e.g., people with Parkinson’s disease, multiple sclerosis), and those on medications that can cause lower leg edema (e.g., amlodipine). Healing ● Non-healing ● Non-healable wounds A healing wound is supported and monitored to ensure the wound progresses to closure. However, it is important for pharmacists to recognize that not all wounds are healable. A non-healing wound occurs when the person has the capacity for wound closure, but makes choices inconsistent with optimal wound healing and/or the healthcare system cannot support optimal healing. An example of a non-healing wound would be a person whose wound requires off-loading (a redistribution of pressure on the plantar surface of the foot to reduce the pressure on the wound), but the person is nonadherent to wearing the off-loading device (e.g., walking cast). A non-healing wound that essentially has the capacity to heal is different from a non- healable wound—a wound that physically cannot heal due to co-morbid health conditions, such as systemic disease (e.g., osteomyelitis that cannot be treated), peripheral arterial disease (resulting in compromised blood flow) or cancer.2 3. ESTABLISH AND IMPLEMENT A PLAN OF CARE Several determinants of care should be considered when establish- ing a plan of care. Pharmacists can support wound care management by identifying people with any one or more of the following issues and engaging the person in self-care to resolve the factor that is increasing the risk of compromised wound healing. Co-morbidities Co-morbidities such as obesity, diabetes with glucose metrics above target, hypertension, hyperlipidemia, arthritis, depression and conditions that affect the health of skin can interfere with the healing of wounds and lead to prolonged or stalled wound healing. By recognizing and engaging the person in self-management of these co-morbidities, pharmacists are supporting the prevention and management of wounds while optimizing health outcomes for the person and reducing the burden to healthcare systems.2 Pain People living with wounds can experience two types of pain: nociceptive pain, an appropriate physiological response to painful stimuli, either acute or chronic, or neuropathic pain, an inappropriate response caused by a primary lesion or dysfunction in the nervous system. Pain can be due to local wound care factors such as dressing changes, debridement, infection and lack of moisture balance, but can also be linked to psychological factors such as depression, anxiety and stress. While many people with wounds may have an exaggerated pain scale score, others will have a blunted pain response due to reduced nerve innervation and advanced, complex wounds. By investigating the factors associated with the person’s pain and appropriately supporting pain management, pharmacists can improve the person’s quality of life and possibly increase the person’s activity and range of motion, thereby improving clinical outcomes and wound closure. Mild pain is managed with non- opiate therapy plus optional adjuvant analgesics, while opioids plus nonopioid and adjuvant analgesics should be considered for more severe pain. People with chronic pain should also be offered appropriately dosed therapy for breakthrough pain.2 Low physical activity Wound prevention and management should involve engaging the person in activity that addresses developing muscle strength (e.g., resistance exercises), balance and flexibility, as well as cardiorespiratory fitness. Exercise positively affects pain, stress, circulation, neuropathy, glycemic parameters and well-being, which are all directly linked to issues of skin integrity.2 Additional strategies People in need of wound prevention and management may require support with smoking cessation, mental health and weight management. Many pharmacists offer these programs. Pharmacists will need to engage the person in shared decision making to determine if a referral is appropriate. LOCAL SKIN/WOUND CARE In establishing a care plan, personal characteristics discussed above (comorbidities, pain, healthy behaviour interventions and additional strategies) must be addressed to support the person with the wound. Identifying and managing the person-centred factors can make the difference between a non-healing wound and a healable wound. Next, the wound itself, needs direct care. In addition to cleansing the wound and debridement, when appropriate (i.e., after determining that there is sufficient blood supply to the wound), pharmacists need to understand the following considerations in local wound care: Bacterial balance Antimicrobial therapy encompasses both antiseptics and antibiotics.2 Antimicrobials may be applied locally in the form of creams, ointments, gels or antimicrobial dressings. In the event that dressings are applied in layers to meet the needs of the wound, the antimicrobial dressing must come into direct contact with the wound bed to be effective.2 Note that the characteristics of the same topical antimicrobial may change depending on the delivery vehicle. For example, iodine can be used in wound management as a cleansing solution and has been shown to inhibit the development of biofilm, a thick slimy barrier of bacteria and fungi that can promote chronic inflammation and reduce the healing of chronic wounds. Iodine can also be applied in the form of a topical ointment. When iodine is delivered to the wound bed via a dressing, a synergistic effect may result as the dressing itself can absorb wound exudate and wick infectious material away, thus reducing the number of endotoxins that often impede healing.2 Topical antimicrobial therapy should be continued for two weeks before the efficacy of the topical antimicrobial is assessed.2 If a local infection spreads to become a systemic infection, systemic antimicrobial therapy should be considered in addition to topical antimicrobials. Moisture balance Effective wound healing requires a proper balance in hydration. During the wound repair process, the body actively brings cells to the site and then clears away debris. This cellular activity requires hydration. However, too much moisture can cause maceration of the surrounding tissues and prevent wound closure.2 For wounds lacking in moisture, a hydrating dressing (e.g., gel) may be preferred. For highly exudative wounds, consider an absorbent dressing (e.g., hydrocolloid foam).2 Dressings Selecting an appropriate dressing, and having the clinical judgment to determine the best time to change an existing dressing, can be challenging for even the most experienced wound care professionals. Dressings are used to support wound management through their ability to balance moisture. If necessary, dressings can also support wounds in debridement, pain management, infection and odour control. Other times, the dressing simply supports moisture balance and is used in combination with preparations, such as topical emollients, topical antibiotics and/or topical corticosteroids. The Wounds Canada Product Picker Wound Dressing Formulary is a helpful resource to understand the differences between various dressings. PHARMACIST’S ROLE The following five points may help pharmacists become more involved in wound care prevention and management: Build your wound care competency (see Wound care resources). Promote wound prevention. Regularly assess for wound risk factors. Address and minimize all modifiable risk factors. Get to know community resources and which programs/clinics will take referrals for wound care. Practise and provide wound care only after a thorough assessment to determine appropriateness of care with people/ caregivers who have the capacity for and are highly-motivated and engaged in self-care. Be educated and educate others in wound prevention and management. SUMMARY Wounds significantly adversely affect people, as they are associated with higher levels of stress, anxiety, depression, sleep disturbance and social isolation.3 Although pharmacists currently contribute to wound prevention through existing chronic disease manage- ment and healthcare support measures, there remains a care gap with wound care in our healthcare system. Trusted and accessible pharmacists can be more engaged in skin health and wound care by being active members of the person’s wound care management team to support prevention of wounds, early identification of com- plications and healthcare system navigation. Greater pharmacist involvement could significantly reduce healthcare expenses and increase access to care, while leading to healthier communities. Susie Jin (susie@pharmacy101.ca) is a community pharmacist whose practice supports people with chronic diseases and aims to minimize acute complications by engaging the person and collaborating with their healthcare team. She has contributed to the writing of Best Practice Recommendations for Wounds Canada. REFERENCES Thambirajah A. Advocating for wound patients in Ontario. Wound Care Canada 2020; 18(1):36-9. https://www.woundscanada.ca/docman/public/wound-care- canada-magazine/2020-vol-18-no-1/1666-wcc-spring-2020-v18n1-final-p-36-39- advocating/file (accessed October 21, 2021). Orsted HL, Keast DH, Forest-Lalande L, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017. https://www.woundscanada.ca/docman/public/health-care-professional/bpr- workshop/165-wc-bpr-prevention-and-management-of-wounds/file (accessed October 21, 2021). Woo K, Orsted H, Gjødøl K. Improving health-related quality of life. In: Wound Care Canada 2009;7(2). https://www.woundscanada.ca/docman/public/wound-care- canada-magazine/2009-vol-7-no-2/353-wcc-2009-v7n2-improving-quality-of-life/ file (accessed October 21, 2021).

Filling wound care gaps

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