A Deeper Understanding of Wound Care - Episode 12
Experts share insight on the standardization of wound care, highlighting challenges in accessing evidence-based guidance.
Peter L. Salgo, MD: What’s surprising to me is that there isn’t a central, focused standard of care. Someplace you can look and say, “Look, I’ve got this kind of an ulcer, here’s what everybody in this field as a consensus panel recommends.” Should there be? Should there be standardization for wound care? What guidelines are out there, and what do you like?
Michael T. Kazamias, MS, DPM: There should be standardization.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There should be.
Peter L. Salgo, MD: There should be.
Michael T. Kazamias, MS, DPM: There absolutely should be. And here’s the good news: they’re there. They’re out there.
Peter L. Salgo, MD: Where? Where?
Michael T. Kazamias, MS, DPM: The centers of excellence, the wound care centers, the home care agencies, the risk groups that manage these particular patients effectively. The challenge is, there isn’t—let me back up and see if I can clarify it a little more.
Peter L. Salgo, MD: Sure. If you say they’re there, and I go look for them and I can’t find them, they’re effectively not there.
Michael T. Kazamias, MS, DPM: It’s there because when you’re treating chronic conditions, the mechanisms for doing that in our healthcare delivery system are well established. The only thing that hasn’t been plugged into that as a skin, is wound care. Chronic wound care has not been treated that way. If we were able to carve it out as an entity, the centers of excellence and the protocols that are established by doctors like Dr Robert Snyder in his center and care centers all over the country, once those are aggregated and plugged into a delivery system that is accessible to the provider and the caregiver with the staffing of the health plan and the payer groups that are integrated into that care continuum, it exists. It’s all out there.
Peter L. Salgo, MD: It was a very quick answer to see if they’re there, but then you went on to say why it’s probably not easy to find it and why it’s not there. And so?
Michael T. Kazamias, MS, DPM: There’s no quarterback.
Peter L. Salgo, MD: If a plan exists in a forest but nobody can access it, does it exist?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: It is accessible. It is something that is available to everyone, particularly with the Internet, etc. One of the main reasons—besides the economic drivers—that hospitals coordinate with companies that will manage their centers is that 1 of those components is they will supply appropriate algorithms that are evidence based. So they can train those physicians working and clinicians of all kinds working in those centers to try to stay within those guidelines. Guidelines are nothing more than guides. Every patient is different. Additionally, many different clinicians are transitioning to wound management from other fields. They have been treating wounds in a particular way for 20 years. It’s very difficult to retrain those individuals to the appropriate protocols.
Peter L. Salgo, MD: You get back to, “Damn it, Jim. I’m a doctor, and I know what I’m doing, Jim!”
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I’ve done it this way for 20 years, and I understand what you’re saying. But this is the way I treat it.
Peter L. Salgo, MD: Walk me through this for a second, because I really want to parse this out. I know what you said. I know that you said that if you look for it and if you think about it, there is a way to approach these things.
Michael T. Kazamias, MS, DPM: Well, from a practical perspective, if Dr Snyder has vast experience in treating wounds, he’s treated tens of thousands of diabetic wound care patients. When 1 walks into his facility, he has a very good idea after doing his appropriate evaluation on how that patient is going to respond to the treatment he recommends, his protocols. The challenge is the primary care physician who is going to see that patient in 2 weeks doesn’t.
Peter L. Salgo, MD: That’s my point.
Michael T. Kazamias, MS, DPM: However, if there were a risk-bearing entity that carved wound care out as a chronic condition, that could access those protocols with technological—and this is sort of a future look, but it can be done because it was done.
Peter L. Salgo, MD: Again, future looks, subjunctive text. Right now, I’m Joe Doc or Jane Doc. Someone comes into my office, and I really want to do this right. There is a wound, I want to pay attention to it, I had the patient take his shoes and socks off, and I see this wound. I’m looking for the path, and I want a codified easy-to-find protocol. Can I find it?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: You can find it, but my opinion is, that if a doctor who does not have an expertise in wound management, particularly in the diabetic population, then that patient should be referred. This is my own opinion.
Peter L. Salgo, MD: Not everybody is going to be referable to a wound center.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Not necessarily a wound center, but perhaps someone in your community [who] has more of an expertise in that area than you do.
Samuel D. Young, MD, MBA, CPE, CHCQM: Correct me if I’m wrong, but you’re suggesting that at these centers of excellence, they have established themselves a protocol.
Peter L. Salgo, MD: Correct.
Samuel D. Young, MD, MBA, CPE, CHCQM: That works for them.
Peter L. Salgo, MD: Correct.
Samuel D. Young, MD, MBA, CPE, CHCQM: I think what you’re getting at is that protocol is not supported by a society and placed out there for acceptance for all practicing physicians in different fields.
Peter L. Salgo, MD: I feel so much better.
Samuel D. Young, MD, MBA, CPE, CHCQM: Right?
Peter L. Salgo, MD: Yes. I know you guys know what you’re doing.
Samuel D. Young, MD, MBA, CPE, CHCQM: There’s not an American academy of wound care.
Michael T. Kazamias, MS, DPM: There is a company out there that was founded some time ago that did exactly that. We worked with the health plan to establish the home care, to establish who their preferred home care agency was, who their preferred risk groups were, or who their risk groups were managing the patients, and where their centers of excellence were in the community. Rather than that wound being sent to or given the option of the patient to find the appropriate care center, that patient would go to the most appropriate care level at the time the patient was identified as a wound care patient. If they went to the center of excellence, the discharge orders would follow that patient because we would coordinate the care, we would forward those protocols to the home care agency so everyone was on the same page with those appropriate care protocols.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I don’t want you to have the wrong impression. There are societies—wound related, dermatologic related, podiatric related—that have established validated protocols that are available. Very often they’re very complex.
Peter L. Salgo, MD: That’s my question. I mean, lots of protocols to me equates to no protocols. Complicated protocols to me equates to no protocols.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: If we only had 1.
Peter L. Salgo, MD: Here’s what I want. I’m a simple-minded practitioner. I want to know what to do. And here is a wound, maybe there’s no clinician really nearby in my community and this person can’t really travel very far. There’s a wound. Couldn’t you just give me some bullet points and help me out here? I’m not hearing that from you.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There are resources, there are meetings, there are journals, there are mentors that you can establish with. I teach at a school of podiatric medicine, and 1 of the tenets that I preach is to find a mentor. If you don’t know how to put on a total-contact cast, find someone who does know and learn the technique. Those tools are out there. It’s just a matter of those individuals who wanted to have access to them.
Peter L. Salgo, MD: Is that too simple? I caught a little no from you when he was talking.
Samuel D. Young, MD, MBA, CPE, CHCQM: Well, I mean, I’m back to what your thought is where there are a lot of protocols, meaning there’s not 1 you can really refer to. We have this problem in orthopedic surgery in many conditions. There’s regional variation in how it’s treated. Until the literature supports strongly 1 specific way, the American Academy of Orthopaedic Surgeons won’t stand behind it and say that this is what we should be doing and publish a real evidence-based guideline. I think that’s what we have here in wound management. There is no academy to drive toward a single accepted evidence-based guideline.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There’s another problem as well. When you’re thinking in terms of orthopedic surgery, you’re looking at orthopedic surgeons. In this particular case, you’re looking at a plethora of individuals from all different backgrounds, and they have their own philosophies as to how these wounds are treated.
Peter L. Salgo, MD: That was my point precisely. You know what I’m looking for. I’m looking for the article, the New England Journal of Medicine article.
Michael T. Kazamias, MS, DPM: AHRQ [Agency for Healthcare Research and Quality] publishes guidelines on pressure ulcer management. They’ve been doing it for quite a while. It has a complete set of protocols.
Peter L. Salgo, MD: It does?
Michael T. Kazamias, MS, DPM: Are they implemented in practice? And who’s accessing that information? How do you access it? In this day and age, it’s not that difficult.
Peter L. Salgo, MD: It’s not hard. But are they getting access? No.
Michael T. Kazamias, MS, DPM: Uh huh.
Peter L. Salgo, MD: They are?
Michael T. Kazamias, MS, DPM: In some instances, they are.
Peter L. Salgo, MD: Sometimes yes, sometimes no.
Michael T. Kazamias, MS, DPM: Yes.
Peter L. Salgo, MD: Which is true for many diseases.
Michael T. Kazamias, MS, DPM: Exactly correct.