Pressure Wound Healing The Three Pillar Protocol

Abstract

Debridement is performed using surgical instruments, but for superficial curettage one can use a modified tongue depressor or the serrated blade of a disposable picnic knife. A non-adhesive dressing coated with a combination of the time honored wound healing materials; honey, maltodextrin, povidone iodine, and collagen, results in prompt formation of granulation tissue. These materials are non-toxic. Overlap of the dressing onto surrounding skin by cutting a noncotton dressing to the size and shape of the wound suppresses drainage. Odor and purulence quickly abates. For more than a decade we have used these materials which cost less than a dollar per treatment. Nurses involved in the cost of caring for a pressure wound know that treatment is a significant and growing budgetary item. In an effort to address this, The Accountable Care act and formation of the Accountable Care Organizations (ACS/ACO) was created and upheld to decrease costs by a ruling of the Supreme Court in 2012. However, simply decreasing reimbursement is half of the equation. These measures "Encourage efficacy through innovation and organization". This paper is an attempt for wound care nurses to meet that challenge. Observation of successful vs. nonsuccessful treatment protocols has resulted in the definition of three distinct but interdependent measures we have termed The Three Pillar Protocol. Offload the pressure. Correct skin failure with micro nutrient supplements. Produce a salubrious environment for the wound to heal in. This can be compared to a three-legged stool. All 3 legs must be equal in length and strength. For example: if everything is in place but the patient is still sitting on the wound during the day or while at dialysis, a pressure wound will not heal. Similarly, if the dressing protocol and offloading is adequate but the patient suffers from skin failure, most commonly scurvy created by vitamin C and other cutaneous micronutrient deficiencies, the wound cannot heal. Thirdly if offloading and supplements are adequate but the wound is allowed to fester in inflammatory debris, the wound will not heal. Arguments have been made against some aspects of the Three Pillar Protocol. But each of the three areas is addressed giving a rationale and background. Currently the disorganized and growing number of expensive therapies is being introduced for purchase. Many treatments promote themselves as one therapy fits all. This in fact is impossible; rather, it is a package which involves all three pillars. With this protocol serving as a guide, wound care nurses and a physician specializing general surgery and nutrition background assumed care of pressure wounds at two nursing homes. At that time many available treatments were being used by certified wound care professionals yielded disappointing results.