Letters to the Editor

Question:

What is the role of wound care specialists in the visiting nurse service, and what are their academic credentials?

Steve E. Abraham, DPM

New York, NY

Answer: There is no standard of academic credentialing in the Visiting Nurse Association (VNA). Larger agencies may require a certified wound, ostomy, and continence nurse (CWOCN) to treat wounds, ostomies, and continence patients under the agency's care. In this respect the role includes consultations to determine the type of treatment, the frequency, and the dressings needed. In this role, based on state regulations, conservative sharp debridement may be a part of the CWOCN's role.

New ostomates need to have ongoing teaching, as well as assessment of the stoma to determine the functioning and appliances needed. Follow-up is important with new ostomates at this crucial time in their lives so that they will be successful with their care and new lifestyle. Continence may be a factor in referrals to occupational therapists or physical therapists for ongoing plans of care.

The specialist will be responsible for formulary development and implementation of the formulary.

Ongoing education is a key component. with competencies for the staff RN performed and evaluated at least annually. (LPN, PT, PTA, HHA).

Networking is another important facet of the role. Many hours are spent working to find the appropriate DMEs to provide supplies to patients, depending on their insurance or lack of insurance. Finding the lowest co-pay for the patient can make a difference in the patient's following the plan of care or not being able to afford the care. Networking with the physicians to build trust in the home health agency is paramount to having a successful wound care program in this arena.

For Medicare patients, maximizing outcomes while decreasing nursing and physical therapy visits has put a positive focus on advanced wound care technologies. Based on the answers to the OASIS, a set payment is assigned for a patient, and the agency must provide all the products and equipment during the 60-day episode.

Certified Wound Specialists are also sought in the home health environment. These advanced practitioners can be very instrumental in all avenues of care of the wound and formulary development. Their focus is wound care.

Many VNAs are sending nurses and physical therapists who have experience in wounds for WCC certification. This certificate does not require a bachelor's degree but does empower clinicians to expand their knowledge and perhaps further their educational goals.

The WCC will go on consultations and consult with the physicians to develop a plan of care and identify dressings to be used. Each individual state's rules governing practice must be followed.

There will be an increasing demand for advanced wound care practitioners in this environment as the population ages and the need for care in the home becomes important.

By Justeen Keahey, MS, CWOCN

Clinical Specialist, Wound Care Division

Ohio Valley Region

Question:

This question was sent for Jaimee Haan's article, “A Retrospective Analysis of A coustic Pressure Wound Therapy: Effects on the Healing Progression of Chronic Wounds” (JCWS 2009;1(1):28-34): For the retrospective analysis, are you able to determine the mean and mode times to heal at your facility overall for comparative purposes? Is this modality effective against biofilms?

Barry Creighton

Lithia, FL

Answer: During this retrospective analysis, we did not capture specific data that would allow us to determine mean and mode healing times on patients not receiving APWT. The goal of this particular study was to determine the change in the amount of devitalized tissue, amount and type of wound drainage, and wound surface area after administration of acoustic pressure wound therapy (APWT). One of the limitations of this study was the lack of a control group, which would have been extremely difficult to obtain, considering that a majority of the patients seen in our department who met the criteria for APWT received the therapy. The number of patients who would have been appropriate for APWT but did not receive it would have been extremely small. I recommend Kavros and Schenk's research, “Use of Non-Contact Low-Frequency Ultrasound in the Treatment of Chronic Foot and Leg Ulcerations,” and Ennis et al, “Ultrasound Therapy for Recalcitrant Diabetic Foot Ulcers: Results of a Randomized, Double-Blind, Controlled, Multi-Centered Study,” both of which had a control group that compares healing times in patients who were treated with APWT and those who were treated with standard of care alone.

As to whether this modality is effective against biofilms, I am not aware of any published data showing the direct impact of APWT on biofilms to date. As shown in Serena et al, “The Impact of Noncontact, Nonthermal, Low-Frequency Ultrasound on Bacterial Counts in Experimental and Chronic Wounds,” APWT is effective in destroying bacteria and does penetrate tissue at depths that could potentially impact a biofilm. However, this study did not investigate biofilms specifically. Further research specific to biofilms is needed to answer your question with any certainty.

By Jaimee Haan

Question:

Is it ever appropriate to use a split thickness skin graft on the plantar aspect of the foot?

From Simon Young, DPM

New York, NY

Answer: Resurfacing the plantar aspect of the foot is a challenging topic for reconstructive surgeons from all backgrounds. Replacing like by like is a basic principle in plastic surgery. However, the lack of available donor sites of glabrous skin makes its replacement difficult. This specialized skin has a thick stratum corneum with long rete ridges and no melanocytes, all of which contribute to its strength, texture, and color. In general, small wounds may be closed primarily or left to heal by secondary intention. In large wounds with no tendon or bone exposure, skin grafting is often performed. However, skin grafting of these wounds offers unpredictable long-term results secondary to the thin epidermis, which is unsuitable for weight bearing. In cases in which tendon, vessel, or bone is exposed, local or free flaps are needed. Alternatives to these relatively complex and invasive procedures have been developed. Resurfacing of a large plantar wound with cultured epithelial autografts obtained from the patient's palmar keratinocytes has been reported. These matured into a tissue histologically similar to the palmar or plantar epidermis, with a thickened stratum corneum and the same color match and texture, and provided durable results.¹ Potential donor sites for split-thickness skin grafts of this specialized skin are available in limited sizes on the hypothenar area of the hand and the medial plantar arch of the foot, which bears the least pressure during walking. These are useful for coverage of fingertips and other small hand and foot wounds without exposed bone and tendons. They are harvested as small grafts or pinch grafts.² Although local composite flaps of the foot are ideal for moderate-sized wounds that cannot be closed primarily, their limited arch of rotation has made their use difficult and limited.³ Another method of closure of composite defects with exposed bone and tendon is the use of artificial skin. This is applied over the defect site as a template to guide the patient's own cells to migrate into this scaffold and build a new pseudodermis, which is skin grafted later. This method provides temporary coverage of the exposed noble structures while the pseudodermis is being formed prior to grafting. A variety of dermal substitutes are available on the market. An example of this product is Integra, which is an acellular bilaminar artificial skin. The bottom layer, which is in direct contact with the wound bed, is made of cross-linked bovine collagen, which serves as a template, and the top, protective layer is made of silicone sheet, which protects the wound from infection and dehydration. The product is incorporated into the wound bed 2 to 3 weeks later, the top layer is removed, and the new dermis of the wound bed is skin grafted. Certainly the use of negative pressure wound therapy had minimized the need for complex reconstructive procedures by reducing the size of the wound or even completely healing smaller wounds.

Many techniques are available for plantar wound closure, but ultimately the reconstructive decisions are made on the basis of the surgeon's level of comfort, training, and expertise in performing one method over another.

By Richard Simman, MD, CWS, FACS, FACCWS

Associate Clinical Professor, Plastic and Reconstructive Surgery

Associate Professor of Research, Pharmacology and Toxicology

Wright State University School of Medicine, Dayton, OH

Medical Director, Sycamore Wound Center, Miamisburg, OH

Thank you for sending this interesting question to the JACCWS.