Chronic wounds represent an underfunded, poorly understood and under-recognised public health issue in Australia, according to the Australian Medical Association’s 2022 report, Solutions to the chronic wound problem in Australia.
The AMA attributes this to a lack of reliable data on the prevalence of chronic wounds in Australia and the impact on the healthcare system and the economy.
Research suggests chronic wounds affect around 450,000 Australians at any time, costing the health system around $3 billion each year, the report says.
The AMA estimates the cost of hospital admissions due to chronic wounds in 2019-20 alone was $352 million, with procedures performed on chronic wounds costing an additional $115.7 million. However, due to limited data, this is likely to be an underestimate.
The lack of reliable and comparable data makes chronic wound prevention and management strategies challenging to implement and evaluate, with no incentive for decision-makers to invest in them.
The AMA notes significant work is in progress to collect reliable data on chronic wounds.
Chronic wounds are most prevalent among people aged 60 years and over and those with chronic health conditions such as diabetes, obesity and cardiovascular disease.
Most chronic wounds are managed in the community rather than in the hospital, with general practices playing a pivotal role in prevention, monitoring, and management.
Chronic wounds need to be managed well. Otherwise, they can result in delayed healing, infections, long-term complications, hospitalisations and amputations, placing great physical and financial strains on patients and an already stressed healthcare system.
Access to evidence-based care lacking
Delivering evidence-based wound care, specifically using evidence-based practices, wound dressings and consumables, is key to reducing the burden on patients and the healthcare system, according to the AMA.
However, barriers to this include inadequate funding for wound consumables, a lack of formal wound management education and training, and the absence of coordinated care pathways.
The costs of providing the appropriate consumables mean a financial loss for many general practices, the report says.
Patients tend to buy consumables from the pharmacy at retail price or seek free wound treatment at community healthcare settings such as hospital outpatient clinics, placing an additional burden on these settings.
The report also points to a lack of access to expert wound advice and care.
This is particularly the case for vulnerable groups such as lower socioeconomic populations and Aboriginal and Torres Strait Islander people already disproportionately affected by chronic wounds and diseases.
Wound care in the community
Managing chronic wounds involves several healthcare providers working as part of a multidisciplinary team across various healthcare settings.
“Community pharmacists triage patients with wounds,” PSA National President Fei Sim told Retail Pharmacy. “They assess wounds for self-management, which includes evaluating the nature of the wound and the patient’s capability of self-managing.
“Pharmacists can also monitor wound healing when patients present for additional supplies. Some pharmacists offer dressing services where they have a formalised arrangement and work collaboratively with local doctors or nurses to provide care.
“Pharmacists work with other professions, including podiatrists, physiotherapists and others who are seeing wounds, for referral, advice and provision of wound care products. Pharmacists let them know what products and services are available and the process for obtaining a specific product that they might not already range in the pharmacy.
“Pharmacists also receive referrals from these health professionals regularly. This is particularly useful for GP clinics that don’t have a wound-care nurse or a particular interest in wound care. There are many examples of this in practice, and some niche examples include lymphoedema/compression garments and mobility services.
“Pharmacists work within referral pathways, referring patients to GPs, emergency departments, or other healthcare providers when necessary.”
The AMA’s report says the absence of a nationally coordinated care pathway for chronic wound management means that care is often poorly coordinated, resulting in poor continuity of care, and that it’s more difficult for patients to be active participants in their care.
Dr Sim says there is scope for pharmacists to have more formalised arrangements working as part of the wound care team.
“For example, there are opportunities for state governments to train to upskill pharmacists in this area and to give patients the option of having their post-operative and chronic wounds managed in pharmacies instead of having community nurses visit their homes,” she said.
“Pharmacists in the GP setting and the aged care setting will have scope to work in this space, although the viability of a service in these settings will rely on the funding model and whether existing providers in the same setting are already providing adequate wound care services.”
Scope for more collaboration
Accredited Practising Dietitian Katherine Dahdah says dietitians can conduct in-pharmacy talks.
“For example,” she said, “the dietitian provides the food perspective while the pharmacist provides the supplementation perspective. Both can touch base on supplement and medication interactions. Pharmacists and dietitians can conduct services for hospital and community nurses.”
Dr Sim added: “An important part of providing a top quality wound care service is educating people about correct wound care techniques and principles. For instance, regular changing of wounds when there’s no infection is something people want to do all the time, yet it’s not best for the healing process. Using the right wound care product for the right type of wound has a significant impact on outcomes.
“Pharmacists who provide wound care services can greatly impact healing, scar reduction, and avoiding antibiotics by educating healthcare providers who are still utilising outdated wound care principles in their practice.
“Pharmacists could offer wound care talks to their community in collaboration with nurses. Wound healing is strongly linked to smoking status, so health promotion around smoking cessation is also important. PSA has held joint learning [sessions] with dietitians to understand the professional practice.”
Nutrition and wound care
Ms Dahdah says nutrition plays a key role in wound healing.
“Poor nutrition,” she said, “slows the healing process and negatively impacts wound tensile strength, collagen synthesis, and immunity,”
“Nutrition needs to support the increased energy demand during wound healing.”
Ms Dahdah provides the following overview of nutrient needs:
- Carbohydrates. Stimulate insulin production. Helpful in the anabolic process of wound healing.
- Fats. Supply additional energy for the wound healing process. If watching your fat intake for heart health, stick to healthier fats such as monounsaturated fats in avocados and nuts.
- Protein. Needed in all stages of the healing process, it’s essential for collagen synthesis, immune function, fibroblast proliferation, angiogenesis, tissue remodelling, wound contraction and skin structural proteins. Overall protein and calorie malnutrition may cause a redirection of protein reserves to other required bodily functions, thereby slowing wound healing. Wounds increase protein demand by up to 250 per cent and overall calories by 50 per cent.
- Amino acids. Arginine and glutamine. Arginine is a precursor for proline and nitric oxide, which are essential in collagen production and the inflammatory process of wound healing.
- Fluids. Maintain skin turgor and promote tissue perfusion and oxygenation. Alcohol can cause dehydration and depletes zinc, an essential nutrient for immunity and wound healing.
- Supplements. These will depend on other health issues patients may have. A range of Ensure or Sustagen products can help meet overall energy requirements. Protein supplements can also support demand. Ms Dahdah suggests Arginaid, L-arginine, and collagen as supportive supplements.
- Vitamins and minerals. Vitamin C and zinc are essential in all stages of wound healing and accelerate wound recovery. Vitamin C supports formation of collagen. Zinc supports the skin and mucous membranes. Given that plasma and tissue levels of vitamin C are depleted, supplementation of up to three to fourth times the recommended daily dosage can support the recovery process. Iron is also essential for healing, helping to maintain blood haemoglobin levels.
Although the best source of nutrients is food, supplements may need to be considered if healthy food consumption is inadequate.
For people with any health conditions, including those that may affect their eating ability, it’s ideal to speak to a dietitian first. Canada’s Alberta Health Services notes that those with diabetes need to manage blood sugar, which is also important during wound healing.
References
- uhcw.nhs.uk/download/clientfiles/files/Patient%20Information%20Leaflets/Clinical%20Support%20Services/Dietetics/Dietary%20information%20to%20promote%20wound%20healing.pdf
- ama.com.au/sites/default/files/2022-10/Solutions%20to%20the%20chronic%20wound%20problem%20in%20Australia.pdf
This feature was originally published in the March issue of Retail Pharmacy magazine.
