Guest Editorial: Toward Improving Chronic Wound Care

    In January 2003, the Canadian Association of Wound Care (CAWC) decided to take a bold step. The membership had been saying that access to both physical and human resources for managing chronic wounds was a major issue — that while the demand for services to treat chronic, nonhealing wounds was rapidly expanding, it did not seem to be a funding priority at various levels in the healthcare system. The CAWC Research Committee had been saying that in order to set research priorities, the extent of chronic wounds in Canada had to be determined.

    To address these concerns and better advocate for our patients and our wound care clinicians as well to set research priorities, the CAWC decided to fund a study of existing databases to delineate the information available on prevalence and incidence of various types of chronic wounds in Canada. The study would help illuminate gaps in this information and set the stage for further research. The data would allow the CAWC Public Policy Committee to create citizen awareness of chronic wounds and their impact on the lives of Canadians to marshall support for the needed resources.

    The study was completed by Drs. Gail Woodbury and Pamela Houghton; the results are presented in a key article in this issue. The authors searched the published literature and were given generous access to some private databases. Prevalence and incidence data exist for pressure ulcers but little data are available for other etiologies such as venous leg ulcers or neuropathic diabetic foot ulcers. The pressure ulcer data were somewhat shocking — one in four patients in an acute care facility can expect to have a pressure ulcer and this rises to almost one in three persons in non-acute care settings. In the rehabilitation and chronic care facility where I work, we have regular access to Quality Indicator data from the Minimum Data Set collected quarterly on all chronic care patients. In our facility, pressure ulcer prevalence averages approximately 10%. Of these, 50% are Stage I and 25% are Stage II. The remaining 25% are divided evenly between Stage III and Stage IV. The distribution of pressure ulcers among the various stages is similar in other databases. Woodbury and Houghton report that the prevalence in Canada is higher than reported in other countries.

    Armed with these results, the CAWC decided to make pressure ulcers a focus of advocacy efforts in the coming year. The Public Policy Committee is working on a public awareness campaign to be launched in 2005. The Public Policy and Clinical Practice Forums at the 10th Annual Conference of the CAWC in Calgary, November 11 - 14, 2004, will focus on this issue. It is also the focus for this special CAWC “Canadian” issue of Ostomy/Wound Management. In addition to the article on the extent of chronic wounds in Canada, this issue contains articles on pressure offloading, nutrition, and a potential new intervention.

    It is often said that we can put anything on a pressure ulcer except the patient. This conventional wisdom has resulted in patients with pressure ulcers being put on enforced bed rest — often for months at a time. Whether this treatment strategy is supported in the literature and what impact it has on the quality of life for our patients raise two important questions. In their article, Linda Norton and Dr. Gary Sibbald explore the literature on this subject and demonstrate that this treatment strategy may do more harm than good. In a wonderful commentary on this article, Laurie Rappl, the current Consumer Representative on the Board of the Association for the Advancement of Wound Care (AAWC), offers the patient perspective.

    Many pressure ulcer patients are elderly. Nutrition plays a significant role in pressure ulcer healing, but determining a reasonable approach for elderly patients can be a challenge. In their article, Connie Harris and Chris Fraser explore a practical approach for managing nutrition in the older patient.

    In the final article, a report from our facility focuses on a potential treatment for anemia of chronic disease that often accompanies pressure ulcers and its potential impact on healing. Recombinant human erythropoietin used in four pressure ulcer patients to treat anemia of chronic disease showed promise but more thorough research is indicated.

    We are also pleased to include in this issue 16 abstracts of poster or oral presentations that were submitted for presentation at our Calgary conference in November 2004. Each year, the CAWC receives increasing numbers of abstract submissions, and after review by blinded peer-review panels these were selected from nearly 100 submissions as representing the best. 

   The CAWC has worked hard over the past years to promote evidence-based interdisciplinary practice in wound care. The abstracts and the articles in this issue underscore this focus. By expanding our networks and with generous sharing of our knowledge, we are working towards a true community of practice.