The Wound Data Registry Project

The current wound care delivery model has failed to standardize outcome measurements and quality offerings.  Decision uncertainty among wound care providers has created a wide variety in practice styles and unexplained clinical variation.  As an industry, the wound care community lacks the ability to control costs.  Lastly, the limited impact of new  scientific information on the clinical practice of wound management has not been met by an effective information delivery method.

The goal of the Wound Registry Platform is to strengthen the validity and the value of the scientific evidence base for wound healing.  The Registry represents a strategic initiative aimed at developing the architecture necessary to incorporate clinical research on wound healing into the National Health Information Network.

Health Related Quality of Life Measurement in Patients with Chronic Wounds of the Lower Extremity

We developed a computer-administered instrument for measuring health-related quality of life (HRQoL) in patients with chronic wounds of the lower extremity.  Our overarching goal was to integrate quality measurement into clinical practice, without increasing physician administrative burden.  A set of uncorrelated questions regarding physical, social, emotional, and functional well-being were developed from a review of the medical literature and electronic health record data extraction.  Content validity was ensured by consensus.  Internal reliability was estimated by the Kuder-Richardson formula 20 (KR20).  We then developed a computer application to display the HRQoL instrument on an electronic kiosk with touch screen interface.  Patients independently responded to a structured questionnaire and their choices were stored in the clinic's electronic health record.  Data-mining software aggregated each patient's data and analyzed it against a continuously growing range of HRQoL values for other patients.  Current work aims to validate our pilot study.

The "Secret Pathogens" in Chronic Wounds

Research into the reasons some wounds have difficulty healing, increasingly incriminates bacteria.  Several studies have found bacteria residing not only below the wound's surface but also locally invading non-ulcerated skin and soft tissue.  New evidence suggests that bacteria secrete "hormone-like" chemicals that help them control their numbers and their activities.  In scientific terms, bacteria appear capable of self-regulating their population density and synchronizing their behaviors - a process known as "quorum sensing."  Quorum sensing may also help bacteria guard against immune detection, improve their resistance to antibiotics, and thwart the skin's efforts to heal.  For some patients, bacterial "colonization" delays or utterly prevents a wound from healing.  In others, pathogenic bacteria might lie dormant in local scar tissue - well after the surface has healed - rekindling an infection or a full-blown wound recurrence when a patient's immune defenses weaken.

Traditionally, wound care practitioners attempt to identify the types of bacteria growing in a wound, using surface swabs and tissue biopsies.  These types of specimens undergo routine laboratory processing aimed at growing bacteria in culture.  However, a large percentage of wound specimens fail to grow any bacteria, even when properly acquired from clearly infected wounds.  A complete understanding of the ways bacteria "hide out" and elude laboratory detection does not exist.  Based on current evidence, however, we believe that quorum sensing plays a lead role in enabling bacteria to escape detection by standard culture-based methods. 

By chemically altering the cell-cell signaling systems used by bacteria to self-regulate population density, we hope to identify previously non-culturable species of bacteria that reside in the skin surrounding a chronic wound.  Ultimately, new knowledge about the diversity of bacteria that inhabit chronic wounds might better inform clinicians' treatment decisions.  It is entirely possible that there are species of bacteria that colonize non-healing wounds currently unidentified by conventional laboratory cultivation.

A Rich Internet App for Wound Care Practitioners

The practice of wound care is information-intensive.  Wound care practitioners must manage, find, display and report their clinical findings.  The need to advance patient safety and deliver high standards of care for patients with complex wounds compels both an expert information system and a mature workflow management scheme.  Three things are needed for their clinical information system to be broadly useful:  (1) ease of access,  (2) clinical decision support for delivery of "best standards" wound care, and  (3) a vehicle for outcomes research.  

We are developing performance measures and information systems that support the ambulatory care of chronic wounds.  We believe that best practice standards will only emerge from well-designed clinical trials, computer-assisted cooperative work and sound clinical data analysis.  Inevitably, wound care practitioners must find their place across the broad rubric of the national healthcare information infrastructure.  We hope to illuminate that path.

Our current research effort is focused on developing, implementing and testing an initial performance measurement set for the care of patients with chronic wounds of the lower extremity.

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