CME Wound Care

The Biological Basis of Healing of Chronic Wounds

Harold Brem, MD

Harold Brem, MD discusses the value of the Electronic Medical Record in a large wound care practice. Dr Brem then shows how the record can easily alert the physician to outliers in care and contribute to better patient outcomes.

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Goals and Objectives
  1. Describe Diabetic Foot Ulcer Treatment Protocols
  2. Explain the Pathology and Microbiology of diabetic foot ulcers
  3. Evaluate the use of Wound Electronic Medical Record in care of patients with diabetic foot ulcers
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  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Harold Brem, MD

    Chief, Division of Wound Healing and Regenerative Medicine
    Winthrop University
    Mineola, NY

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    Harold Brem has disclosed that he serves as a Consultant and on the Speaker's Bureau for Organogenesis.

  • Lecture Transcript
  • [Presenter] So we�re going to move on next, and Dr Brem is here with us, and I met Dr Brem once in the past, but he�s a gentleman that if you read, you know that he has published and he�s now in charge of his own wound division, and he�s been funded by the NIH, and he�s certainly somebody that�s, he�s one of those names that you see out there that has been just associated with tremendous research from New York. So Dr Brem, thank you.

    [Dr Brem] So xxxx and Dr Frykberg, it�s really an honor to be here. Our division has been in New York for the last 13 years, and recently I�ve reunited with my former administrator, who became vice-president of this hospital, and he said, �My gosh,� he said, �all that time talking about the diabetic foot, why research was important, why orthopedic surgery was important, plastics, vascular and podiatry,� he said, �we have it all here � we have a wound, we have a true wound center. We�d really like to make this integrated.� And when we started doing an in-patient unit back in Columbia in 2004, it was really a radical idea, and they set it up in a way � it�s was just like the transference center at Pittsburgh. Actually, he said, it was really similar. They realized that to take care of the diabetic foot and pressure ulcers in chronic wounds, really requires the multiple disciplinary approach.

    So it�s really a great privilege to be here with you and share some data. And I write as Dr Gorenstein, who actually directs the center, as my co-presenter today. Okay. This work was supported by the following grants, and, including a recent one, which Dr Frykberg helped me obtain, which is to mentor students at all levels and junior faculty.

    So our program is 24/7. It�s an outpatient wound center. Outcomes of clinical research, and of course education of all those that come through. We rely on all aspects of care, both from the regenerative medicine aspects to conventional surgery, and that is a pointer for today, is to discuss what our goals are. So we postulate that we could significantly decrease the amputations if we knew everything for every patient simultaneously not sequentially. Decreasing the morbidity and mortality in the elderly specifically with diabetes, defining the protocol, and I think the most important part of this talk, as we talk about electronic medical record is, it�s not the electronic medical record but what we�re putting in it, and what you need the electronic medical record for is what? The pathology and microbiology, and as those evolve in the treatment of the wound as it progresses, you need a way of keeping track of that because the protocol changes accordingly.

    So who do you really need to heal an ulcer? Before you get what you put into the electronic medical record, I think that�s, it�s more which specialties are actually going to contribute to it. At the end of the day it�s going to be a medical assistant or somebody who objectively could put the date in, who�s not going to cost a fortune, and could present the data too objectively, but who is it that is taking care of the patient? So it�s nursing, maybe the home care nurse, diabetes educators are important, the vascular surgeon, whichever parameters are being used, physiatry for rehab and how they�re going to walk on the foot, endocrinology, ICU when the patients present septic and so forth; nutrition is exceptionally important; infectious disease; emergency room physician, orthopedic surgeon, cardiologist, many of these patients are presenting with some element of heart failure, as well as nephropathy; plastic surgery; the ophthalmologist, retinopathy, radiology, general surgery. And seizure�s very important. Pain management. Psychiatry and what I rely on the most are the physician assistants who actually run the in-patient unit for these wounds. You�re not going to have all of these, but you�re going to have components of these in each and every patient.

    So what led us to have wound electronic medical record and the need of wound photography was this initial experiment that I did with Dr Folkman when I was a fellow. At that time I was a general surgeon, and like any good general surgeon, I hated wounds, didn�t get better right away and so forth and so on, but I had done some work with him previously, and we were measuring whether the first angiogenesis inhibitors, which later went into clinical trial � 1992 was a first � did it affect wound healing? They wanted to know that. So I said, okay, you know, pretty simple experiment. Look over here, and you can see there�s an inhibition. After studying several thousand mice, we figured that if you give the inhibitor five days after surgery you�d be safe.

    And here�s how you measure a wound. This is very important. 100% healing, and there was a five-day delay. And we came to learn that angiogenesis was time-dependent; revascularization and photograph was critical for objective parameters. We couldn�t treat a wound without it. I was shocked in 1998 when I started treating these wounds. Photograph and an EMR was not part of the record. This was way before EMRs became popular. In fact between the VA and my wound center it was about seven miles. I wouldn�t treat patients unless they had a picture, they had an EMR and all the data was presented to me. I couldn�t survive in two separate centers, and I had a $2.5 million grant from Jim Peters - it�s the Jim Peters Bronx VA � to treat patients here, and I was just running him back and forth as a junior faculty member. And this is what the EMR looks like, and I specifically don�t want to emphasize how the EMR looks, but, and we don�t have the actual X-ray up, but the graph that you just saw from those mice is critically important. If the wound�s getting better, I don�t really care what the microbiology and the pathology is. I don�t really even care what the offloading is. It�s going down, I�m happy, I�m on to my next patient. I don�t care that much about the vasculature. I don�t care much about recurrence. I don�t care about the nutrition. But if it�s flatlined, or not decreasing by let�s say a certain percentage, and really going down, you have to make a change, and you cannot make this without this EMR.

    So the future is here. It is impossible for you to take all the variables. Turns out there are 128 variables that you have to know on every exam, about 27 of which are relevant to make that decision. And when it�s not going well, by having it all on one sheet of paper, I think color coded, but at least on one sheet of paper, you can make the variation. You can say, �Look, the argument�s 2.8. You�ve got to take xxxx� [7:50] and so forth and so on. Now, if you don�t have this tomorrow, if you want to talk afterwards about which one to get, if you don�t have EMR tomorrow, at least you could do the checklist. And Guandi wrote this great book on checklists. It�s absolutely imperative that you have this checklist in practice.

    And this is what�s in the database in your checklist: a photograph of the wound, wound location, drainage. I am, you know, I have a high-volume practice, and I want to let you know this is all very practical. This saves you time. It guarantees you that each and every one of your patients will improve. I mean, if they need amputation or not, you�re going to know that by the second visit, if they�re not responding to your therapy and so forth, whatever. But you don�t want to go a month, and certainly not longer, with them not healing and improving. If you do this checklist they will do well. I emphasize to you that beyond the checklist and beyond the EMR, the pathology and the microbiology of the tissue you leave behind is critical.

    Now, some things you could add into your database are quality of life and pain. You know, I�ll tell you the best clinic I�ve ever seen is Dr Frykberg�s clinic. I started off with a research collaboration, but I never saw care of patients in there. And I don�t know if we could all measure the parameters that he does for every single patient or have that type of outcome. And I add qualities of life and pain, because I�m not sure you need to do that for every patient. So pathology and microbiology are critical; quality of life and pain may not be. And you have to tailor-make it to each individual clinic, but you also have to set up what the expectations for your clinic are.

    But this is what it looks like. With an EMR, the future is here � and again, it�s just like what we saw, regenerative medicine and cellular therapies and the contact cast boot � and so many other things. And you know, gastroc surgery, plantar osteo � nothing by itself works. So at the end of the day you have to look, and you have to say, how many diabetic foot ulcers do I have that week? How many didn�t heal? And those are the ones that we discuss at our weekly conference. So every week from Monday, 7 to 9, we have a foot section, we have another section 7 to 8, 8 to 9 � all these different specialties come and participate, and if they�re not healing, that�s our morbidity and mortality � that�s our complication. And that�s, but the EMR can generate that data for you.

    We know what the protocol looks like. This is the end of what is a truly spectacular meeting, enormous glee in seeing so many so dedicated to this field. We know how to do this, so � but, make sure that you have your protocol posted so everybody else on your team could do it also. So when you�re, you guys are motivated, but maybe, maybe the medical assistant or the student is not, who�s part of the team. So just a good reminder to have this posted.

    The wise protocol � and I�m using that as an EMR, necessary � because when you have this degree of undermining, the EMR will light up and send you a clinical decision support. And that means it might give you a reminder on your iPod or on your Blackberry or it might just be the nurse calling you saying there�s undermining. That�s a very different disease and this patient died of sepsis three days later, which alerted me that undermining was a significant potential morbidity and mortality.

    But if you follow protocol, and you don�t have undermining, no matter what the hemoglobin A1c is, you should expect rapid healing with all the modalities that you�ve heard about during this session. So the EMR could be extremely useful to you as part and parcel of a constant checklist and organized program to say, okay, you know, we now know that undermining can result in this problem, and therefore we need a clinical alert when that happens. It might be ischemia in your program, depending on who you have working � these things might be happening all the time. Obviously if you�re doing the surgery there, I don�t anticipate too many problems in ankle surgery and so forth � that�s the largest series in the world. But not everybody�s going to have everything.

    What do I mean by the pathology? And I think this is the part that�s undertreated the most, and I think it�s, if there�s one take-home message for your EMR or your checklist, it�s to check the pathology of the tissue you leave behind. We now know that if you debride this area, (a) the officer and the inspector-general will come in and ask you why you�re debriding every week, but we now know why we need to debride out to this area. So we just need to take a 20 blade and sort of take a square, and take out the soft skin, the hyperkeratotic

    tissue and the ulcer. And the reason is, because this tissue over here, this outer soft skin, believe me, if you�re, no matter how big the ulcer, if you follow this, this will save you a lot of angst in the operating room. This tissue has four layers of keratinocytes. Yes, they are physiologically impaired, but this layer, through certain genes, that we and others have identified, will cause 20 layers of cells. These are abnormal keratinocytes � they don�t migrate. And therefore you have to train your pathologist every Wednesday from 9 to 10 � I want you all to come to New York, only nine miles from Kennedy Airport is, we look under the scope and we say, �Boy, if that person�s not healing and they�ve got ten layers of abnormal keratinocytes they probably need a redebridement further wide.� Just like a tumor case. The tumor cells, if they have that bunch of abnormal keratinocytes, anything you put on them is going to be abnormal.

    So defining the pathology and the microbiology is extremely important. All these articles are referenced here and available to you, and of course through further discussion.

    Even this patient, who has a hemoglobin A1c of 13, coming in septic, by following these principles, you could see here we did a wide debridement, and working with Dr Bolton in this protocol we said that every wound is expected to heal if you follow these principles.

    What does the pathology look like? Healthy granulation tissue at the base. But now we just talked about what the edge looks like; now I�m talking about the base. If you have fibrosis or necrosis or osteomyelitis, which is, I didn�t show it to you now for the sake of time, but neutrophils coming into the lamellar bone, you know that you�re not going to heal. So always take that rongeur of the tissue you leave behind, drop it into the path. At the very least you�re releasing endogenous stem cells; you will never do any harm. I wouldn�t go if the cortex is intact and you�re far away from it � that would take a piece of bone, obviously. But if a wound probes down to bone, take out a piece of bone, and as we, do you know, as was just said so nicely in this session, you�re never treating the wound, you�re treating the entire bone � it�s probably got osteo in it. Take it for path, take it for culture.

    I say stem cells, but these are really endogenous cells that you�re applying to a wound, and my point is, if you don�t follow wound EMR you wouldn�t know that the underlying tissue was infected. Then your cell therapy will be effective in healing. That�s my take-home message. The wound looks terrific, but he went 17 years with a neuropathic ulcer with non-healing.

    Now, about pressure ulcers, I loved the talk that we had in this session about heel ulcers. Those are pressure ulcers. The same treatments, using whether it�s cell therapy, combination with hyperbaric, partial calcanectomy, the vac, use them all in combination � not sequentially but simultaneously, and the heel pressure ulcers will heal. It was great to see the series of those patients being presented.

    Xxxx [16:45] I had saved a shorter version of this lecture, so I�m concluding. I want you to do back to the laboratory, just as a reminder that, just came out with this work that accelerated healing of VEGF works. But if you don�t have built into your EMR, that�s a great laboratory discovering a lot of things coming out of the laboratory. But if you don�t have your EMR program, are you using the FDA approved treatments? You�re going to get amputations. You know, the evidence counts, we all agree on what the treatments are, but

    there�s no use doing further laboratory work if we�re not already putting it into our checklist and our EMR. And there are many studies coming out of the lab and so forth.

    One other question that�s in your EMR. Again, we all know that the EMR is important. We know why and electronic medical record�s important for communication. We all know it�s time-efficient, it helps our practice and so forth. But the questions that tend to be frustrating are, have we defined all the clinical parameters? So ischemia�s a very important one to define, because every vascular surgeon I work with has a different definition of ischemia. So take it from me the hard way. Don�t send a consult in for revascularization. Know what their definition is, and if you use ABIs, if you use, you know, I would personally urge you to have a very low threshold for magnetic resonancy angiogram or CT angiogram. Get a roadmap. Again, if you go to Dr Frykberg�s clinic, you�ll see a beautiful anatomy for every single patient. It�s not � and a low threshold for the testing, and a very aggressive approach for popliteal atherectomy and so forth and so on. But this is ischemia � this is just decreased angiogenesis. Completely different disease.

    ABI of 0.85 probably means you have some of your intrapopliteal vessels, which have 50% atherosclerotic plaque. So use your EMR as an objective way to sort of take out the emotion of when you�re working with 21 clinicians. We have 9, in the last two weeks, we�ve had 9 different surgical groups operate on 31 patients, and it�s really amazing to me � we�re all following the same principles, but it comes together at this one conference, but different surgeons have different definitions of ischemia. But as long as everybody�s following that, so let your clinical alert from the EMR be, there�s ischemia present.

    So what can we conclude? It�s an effective interdisciplinary team can substantially reduce diabetic foot ulcer related lower limb amputations. Wounds heal with the same frequency in elderly and younger patients. I didn�t show you all of the data with that. But I did want to put it out there. Diabetic foot ulcers near 100% healing in the absence of ischemia. I think we�re getting to 90% healing even in the presence of ischemia. Use a wound EMR with clinical decision support, and I want to define that. It�s not only an alert on your Blackberry. It might be a nurse calling you up or somebody, or could even be the secretary saying the results came back with MRSA. Heel pressure ulcers, some patients� diabetes, prevents a Stage 4, in other words, keep track of your healing rates prospectively, particularly for the pressure ulcers. You could expect the early ones not to get to the point of calcanectomy. So today, earlier that they do heal well, even if you do need to do a calcanectomy.

    The future? Well, we�re going to be talking more, I hope. Dr Frykberg, that I just wanted to give you nine ways that I could be reinvited back to this spectacular meeting. In case you were wondering. If not, if I don�t have a guarantee, I promise to spend the rest of the evening talking about it. Thank you very much for the time.