Challenges for skin and wound care in the new century

Advances in Skin & Wound Care,  Sep/Oct 2000  by Harding, Keith

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There has never been a better time for wound care to mature as a specialty.

Our payers, our patients, and even the health care systems that employ us are increasingly demanding that our practices-from the assessments we perform, to the diagnostic tests we order, to the treatment options we choose-be based on evidence of efficacy. They are challenging us to operate at a higher standard than ever before. The question is, can we rise to the challenge?

History Lesson

Humans have had wounds-and various means of treating them-since humans have been humans. Despite this long history and the significant burden wounds pose to health care systems, clinicians had limited interest or expertise in the subject.

That changed nearly 40 years ago, when Winter and Scaled published their paper on the benefits of moist wound healing. It was the stimulus we needed to jump-start an interest in wounds. As a result, many initiatives have occurred in recent years to improve patient care.

Progress and Challenges

We should congratulate ourselves on making such progress in a short period of time. However, we should also recognize that there are huge challenges ahead, especially if we are to be accepted by our colleagues as providing significant benefits to patients.

One challenge is the fragmented way in which many developments in wound care occurred over the years. There was little, if any organized effort to raise awareness of the subject and to improve the standards of wound care delivered to patients within a health care system. Most advances could be attributed to enthusiastic individuals who pushed wound care to the forefront at their institutions. This may seem suspect to our colleagues in other specialties, who are accustomed to advances in patient care being driven by scientific data.

In many ways, the structure of wound care delivery has progressed. Yet our understanding of the principles behind the care has not kept the same pace. Many of us are aware of how little we really know about aberrations in the healing process, the factors that truly predict pressure ulcer development, and the problem of diagnosing infection in many wound situations. The diversity of these challenges requires further research and evaluation to ensure that optimum care-based on the evidence-will be available.

Choosing an Intervention

In addition, clinicians are now faced with a bewildering array of increasingly complex wound interventions. Who will decide which interventions are to be used on an individual patient? How will that decision be made? Is there a need for diagnostic tests or some form of assessment of the patient's response to an intervention before continuing with any novel or expensive therapy?

We are practicing in an age of exciting new therapeutic options. One of the dangers inherent in the eagerness to try the latest technologic advance is the potential for clinicians to forget the benefits of older, more traditional interventions. It is important to recognize that many interventions that have been around for years do not have evidence to support their usage. Does that mean they have limited benefit in wound care? Or does it simply mean that they have never been looked at in a structured way? Does that suggest an opportunity for the research we need for evidencebased practice?

What Don't We Know?

Many challenges exist for individuals interested and involved in wound healing. If we are to rise to these challenges, we should acknowledge what we know and, more importantly what we do not know. We should be prepared to adopt a flexible, innovative, and professional approach to the ongoing, common, expensive, and frustrating clinical problem of wound care, which today, at the dawn of the 21st century, still has enormous hurdles to overcome.

Professionals involved in wound care should not ignore the enormity of the challenge. Nor should we forget that sufficient evidence for us to be accepted as health care professionals will not be produced by just 1 research experiment.

We should accept that we will need to face these challenges if we are going to move forward as wound care specialists in this new century.

Reference

1. Winter GD, Scales JT Effect of air drying and dressings on the surface of a wound. Nature 1963;197:91-2.

Keith Harding, MB, MRCGP, FRCS

Keith Harding, MB, MRCGP, FRCS, is the Director of the Wound Healing Research Unit at the University of Wales College of Medicine, Cardiff, Wales, United Kingdom.

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