Chronic wounds: a clinical problem requiring ownership and coordination

Abstract

In the Scholarly Review on chronic wounds in this edition of the BJD we have produced comprehensive and concise reviews of four aspects of this orphan subject.1-4 It is anticipated that after reading these papers there would be greater acceptance that this clinical problem requires urgent, systematic and comprehensive investment and support that results in patients receiving quality care from a range of clinical staff and specialities as today wounds are seen by many as a subject with no legitimate home or clinical focus. In the paper on the epidemiology and economics of chronic wounds it is apparent that we do not have comprehensive and robust datasets that describe the extent of the problem of chronic wounds.1 There is conflation of specific wound types such as diabetic foot disease, venous ulceration and pressure injury with wounds that have been present for specific time periods such as 4, 6 or 13 weeks. The duration of ulcer is not linked to any biological process and is an arbitrary figure. It is likely that changing demographics and patterns of disease will result in patients with chronic wounds increasing in numbers and cost going forward.5 A review by Guest et al. published in 2020 showed that the total burden of wounds in the UK was £8·3 billion and £5·6 billion was due to treating chronic wounds, with 80% of costs incurred in the community where there is significant potential for fragmentation of care.6 They also showed that over a 5-year period from 2012/13 to 2017/18 the prevalence of wounds increased by 71% and the cost increased by 48% in real terms. These data should convince even the most hardened sceptic that chronic wounds are a clinical problem that need attention. The treatment options that could be used to treat patients with chronic wounds are diverse. However, there is a lack of comprehensive, robust and reproducible evidence to help clinicians select the best option. In our review paper we consider dressings, devices, drugs, surgery and biologically based interventions as potential therapeutics.2 An aspect of patient care that is often missed in current practice is a clear expectation of whether there is a focus on dressing, caring for, managing or healing the wound. This can result in both inappropriate and ineffective choices being made and the inefficiency of current-day practice has significant potential for improvement. The biological and molecular response to wounding is still emerging and is poorly understood by most clinicians. Similarities and differences between tumorigenesis and wound healing form the basis of a diagnostic test that has the potential to identify individuals with chronic wounds as either healers or nonhealers.7 This may seem rather contrived but could be a means to engage clinicians in the subject and illustrate its complexity. One of the components of healing is inflammation. Appropriate levels and duration of inflammation is required if healing is to occur. Abnormalities in inflammation can result in chronic wounds and include a range of inflammatory skin diseases. It has been shown that 3–5% of skin ulcers are due to vasculitis, and vasculopathy resulting in calciphylaxis is present in 5% of patients with end-stage renal disease.3 The treatment options for inflammatory ulcers include the use of topical and systemic steroids and immunosuppressive drugs. These drugs are not without risk and should be prescribed only by clinicians with expertise in such conditions. As such, it is not surprising that there is often a delay in diagnosis as the usual care of chronic wounds is delegated to a nurse with the instruction to dress the wound without appropriate medical involvement. Another challenge that requires attention is both the diagnosis and treatment of infection in chronic wounds.4 In the majority of clinical facilities today there is still a mistaken belief that growth of organisms alone from a superficial wound swab taken from a chronic ulcer makes the diagnosis of wound infection. This may be the case in other wound situations but is not the same in chronic ulcers that have been present for some time. The challenge that needs addressing by microbiological researchers is how to use modern techniques to identify the microbes and their form that is causing clinical infection rather than colonization of an open wound. There is also a need to clarify the role of bacterial biofilms compared with planktonic bacteria in causing clinical infection. The concept of biofilms being a major cause of nonhealing wounds is compelling but to date there is no validated, noninvasive and reproducible test that identifies and locates the position of a biofilm in an open wound while, similarly, there is no comprehensive evidence to suggest that specific antibiofilm interventions can convert wounds to a healing state. One of the major underpinning issues to focus on in managing patients with chronic wounds is by whom and how that service is delivered. Rather than spending huge sums of money for patients to have regular dressing changes both in hospital and in the community should we not be creating teams in clinical areas and facilities where patients with chronic wounds are supported by an Interdisciplinary team that includes a wide range of professional disciplines including doctors, nurses, podiatrists and professions allied to medicine? They could act as change agents in terms of education, research and development of pathways of care that are evaluated and regularly reviewed. When a clinical problem is affecting such a large number of patients and consuming such large amounts of resource from healthcare systems surely there is a need to improve the current ways in which patients with wounds are managed. No single professional group or new intervention is likely to resolve all the issues raised here. The central platform for this approach is Innovation: this includes technological innovation, system, service and process innovation and social innovation. This would be supported by Impact of the initiatives: from reducing the frequency and cost of treating chronic wounds through to social innovation through which developments like the Lindsay Leg Clubs provide a means for patients and relatives to be more involved in care. The third I of this concept is Invention: encouraging academics, clinicians and industry to work together to address the unmet need for better diagnostic and therapeutic interventions that ensure optimal care is provided to patients. The fourth I is Improvement: through systems that address quality improvement aimed at reducing waste, harm and variation in practice. The final I is Implementation: it is known that changes to practice take too long to be rolled out at scale and speed. These initiatives should include projects that focus on education, research, clinical and service developments. This is a call to arms to ensure that in the 21st century we are more capable of dealing with a clinical challenge that is common, expensive and has substantial potential for improvement. It is anticipated that dermatologists, and multiple other medical specialities, would have a major role in driving these developments forward.

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