“When it comes to complicated wounds, it is important to acknowledge that we cannot do it alone,” argued David Davidson (Buffalo Medical Group, Buffalo, USA), before emphasising that “we need a truly multidisciplinary limb preservation team” during his presentation on team approaches to wound care at the Desert Foot Conference (4–7 December 2019, Phoenix, USA).
It is estimated that approximately seven to eight million people in the USA are affected by non-healing wounds, while nine million are thought to be suffering from peripheral arterial disease (PAD). “In terms of diabetes,” Davidson added, “there are about 30 million struggling with this disease in the USA. This is a very expensive disease to manage, and it is incredible how much is spent on it worldwide.”
In addition to the podiatrist and vascular specialist, the speaker underlined that both the patient and their caregiver must be part of the wound care team. He said: “We need to get both of these persons involved in the care, as this could eliminate some of the lack of judgement these patients encounter as well as issues with non-compliance.”
In a wound care setting, which may be a specialist centre or virtual, the interdisciplinary team work to coordinate inpatient and outpatient services, with the goal of treating the patient and preventing recurrence. According to Davidson, the literature shows that a delay in seeking treatment does slow or prevent healing and has a direct impact on morbidity and mortality. “As part of the process, we exclude and/or treat infection, speak to immune specialists who can take ownership of the patient’s antibiotic coverage, and rule out any vascular disease or—where found or suspected—refer said patient to a vascular surgeon or specialist,” the presenter explained.
Davidson also highlighted the role of the vascular surgeon in this interdisciplinary team, who must decide whether to perform a bypass endarterectomy or another procedure, such as atherectomy or balloon angioplasty, on patients with critical limb ischaemia (CLI). Citing the results of the SPINACH study—a multicentre investigation which enrolled 548 patients—the speaker pointed out that no significant difference was found between the group who underwent surgical reconstruction and the cohort who received endovascular therapy, in terms of three-year amputation-free survival.
However, based on his conversation with a vascular surgeon, Davidson was keen to acknowledge that there are different views in this debate. “Speaking to a vascular surgeon, who probably completes around 40–50 angiograms a week, I asked why, despite conducting so many angiograms, she only carried out three bypass procedures last year.”
He continued: “With open bypass, in her hands, limb salvage rates were as high as 80% over five years, with a mortality rate of less than 6%, and the complications were limited. I wondered why she was not completing more bypass procedures; she said that the complication rate she encounters in performing bypasses is still about three times higher than that of endovascular therapy.”
Turning his attention back to the potential of a multidisciplinary approach, the presenter revealed that by implementing this system, the Netherlands were able to decrease amputation rates by 34% in less than two years, with similar results achieved in Finland, Italy, Lithuania and the UK by wound care units involving vascular specialists. “In the teams that work with one another best, the key is communication. If you are in the same centre, it is generally easier to communicate, but if not then you must stay in contact so that patients can be seen and referred as quickly as possible,” Davidson asserted.
The speaker also acknowledged the need for guideline-specific regulations; these do not have to be exactly the same as what has been published, he emphasised, but they need to be close so that everyone in the wound care arena are “on the same page”. “In addition, we have to decide which guidelines are more appropriate for the studies we are conducting and most importantly, the population we are dealing with,” Davidson added.
He concluded: “When the perfect balance has been achieved between medical management and maximum perfusion, as well as offloading, moisture balance, infection control and patient cooperation, the wound is much more likely to heal in a rapid fashion. Balancing all of these various elements is the job of the wound healing specialist, who must work to organise the internal surgeon, nutritionist, vascular specialist, nurse, podiatrist and several other roles: in situations like this, they must choose wisely.”