Wound Bed Preparation: 25 Years of Reflection and Progress for Low-Resource Communities

Wound Bed Preparation (WBP) was introduced at a Canadian Advisory Board in 1999 and published in the fall of 20001 with the first international meeting taking place in Paris in 2002.2 In this issue of Advances, we present the seventh version of this original paradigm. For the first time, WBP-2024 focuses on resource-limited settings, which can occur in any country. Congratulations to lead author, nurse Hiske Smart, Secretary General of the World Union of Wound Healing Societies. The World Health Organization has highlighted the increased incidence of Type 2 diabetes in low- and middle-income countries with lower-limb amputations occurring every 20 seconds. Even the minor loss of a toe is associated with a decreased 5-year survival and increased risk of further lower-limb amputations.3 The current WBP model recommends that a patient’s glycated hemoglobin (HbA1c) be 8% or lower to facilitate healing and BP be below 140/90 mm Hg as recommended in the WHO targets for 2030.4 The current WBP-2024 documents an assessment to perform the regional VIPs (Vascular supply adequate to heal, deep and surrounding Infection management, and Plantar pressure redistribution combined with appropriate debridement methods). A palpable dorsalis pedis, posterior tibial, or peroneal pulse is usually adequate for healing. A verifiable check for healing is performed with an 8-Megahertz portable bedside Doppler. Any multiphasic audible handheld Doppler signal can be used to rule out arterial disease with an estimated ankle-brachial pressure index of 0.9 or higher.5 This test takes only a few minutes while the patient sits, is not influenced by calcification of the lower leg arteries, and does not require squeezing the calf with a BP cuff. The signal can be recorded on most cell phones and emailed in a MP3 or MP4 format for verification. This test alone can save transport to a secondary or tertiary center for vascular testing. In Northern Canada, evacuation flights are expensive and could be avoided with a vascular specialty team verifying an audible multiphasic signal; however, a monophasic result requires a more detailed vascular assessment for a dilatable or bypassible proximal arterial lesion. The Doppler test result should be complemented with clinical examination of the foot to rule out a cold extremity with dependent rubor that blanches on elevation. With an adequate pulse, this could represent a local angiosomal defect. Infection management can also be improved. Patients with three or more of the five NERDS clinical signs require topical antimicrobial coverage whereas those with three or more of the seven STONEES criteria require systemic antimicrobial coverage.6 In the past, this was often facilitated with IV antibiotics, especially if osteomyelitis is present. However, recent evidence indicates that some oral antimicrobial choices, often at a higher dose, are not inferior to IV antibiotics,7 and can facilitate treatment in communities with limited resources. Although, ideally, plantar pressure redistribution is achieved with a contact cast or a cast walker made irremovable, the International Working Group of the Diabetic Foot recently revised their guideline recommendation to accept any plantar pressure redistribution device that is available through the healthcare system and is acceptable to the patient.8 In South America, the Guyana Diabetes and Foot Care Project was successful in reducing amputations by 68% with an all-purpose boot with a heel backing and Velcro ties instead of laces.9 The inserts were made of Plastazote (Zotefoams) and Poron (Stockwell Elastomerics) with felt and foam for adjustments. This initiative also incorporated VIP, HbA1c, and BP monitoring.9 Through project ECHO Ontario Skin and Wound, we are moving knowledge, not patients, with virtual skills training10 and the development of interprofessional teams within Canada. When possible, we treat persons with diabetes (neurotropic, ischemic, or neuroischemic foot ulcers with and without infection) in their own communities. More complex cases or persons requiring an amputation are usually moved to secondary or tertiary centers. With WBP-2024, there is an opportunity to link education to improved patient outcomes and healthcare system change. R. Gary Sibbald, MD, Med, FRCPC (Med Derm), FAAD, MAPWCA, JM Elizabeth A. Ayello, PhD, MS, RN, CWON, MAPWCA, FAAN References for this article are available as supplemental digital content (https://links.lww.com/NSW/A181). Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.ASWCjournal.com).

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