Managing Lower Extremity Wounds with eConsults

May 10, 2024

Managing Lower Extremity Wounds with eConsults
Patients often have limited access to wound services because 90% of wound and ostomy nurses work in hospitals. However, these limitations are overcome with the use of photos and videos provided by the in-person provider to Corstrata wound care nurses. These wound care experts offer best practice guidance on wound assessment, cleansing, dressing changes, the timing of those changes, the selection of dressing, and antibiotic use. The patients they care for through AristaMD eConsult services often have chronic wounds or ostomies. eConsults are particularly valuable for these patients, reassuring primary care providers that their patients receive adequate care, even in remote or rural areas.

At Arista MD, requests for wound care services originate in two areas, primarily those without access to a convenient wound care center or a major hospital that would have a wound care nurse.

  1. Rural and remote settings: For patients who would otherwise have to endure a helicopter flight for wound care, the convenience and accessibility of eConsults are invaluable. This technology bridges the gap, making them feel empowered and included in the healthcare system.
  2. Elderly populations: eConsults requested for patients over 65 often relate to post-surgery care or chronic conditions. These patients usually face challenges related to mobility and transportation, and time off for their caregivers. Wound care nurses make a huge difference in the lives of these patients.

eConsults allow primary care providers to tap into specialist advice. A PCP can’t possibly keep up to date with advancements and expertise across more than 70 specialties and subspecialties. eConsults help PCPs augment their knowledge, enabling them to access and follow, often changing best practices as new research and treatment approaches become available. They can act confidently when developing a treatment plan or obtaining a second opinion. The PCPs requesting eConsults receive guidance on treating the patient in the practice and receive direction on how the patient can care for the wound at home.  The advice provided, particularly from wound care nurses, is not only related to the treatment the PCP will provide but also includes self-care instructions and warning signs that the wound is not healing correctly.

These services also keep costs to the patient and the practice at a minimum. Organizations operating under a value-based care model can provide diagnosis and treatment in a convenient location to the patient. Patients challenged post-surgery healing, with a chronic condition, or who must take a flight to access care services, like many of our patients in Alaska, benefit from care close to home.

Treatment in the clinical setting is tremendous savings in both the physical and logistical burden of travel and the cost. In addition, wound care nurses allow the PCP to follow the protocols of long-term care facilities, skilled nursing facilities, and inpatient rehabilitation while allowing that patient to receive advanced care and best practice treatment from their PCP.

With an eConsult, the PCP can understand and select the appropriate advanced dressings. In this area of medicine, best practices and technology change rapidly.

What to include in a Wound Care eConsult

Lower extremity wounds are the most common eConsult request. A wound care eConsult requires a photograph of the wound. The picture is critical to determining the primary etiology of the wound, which guides the treatment plan. The patient’s medical history, including comorbidities and complicating factors, should also be included in the eConsult.

Using best practices and extensive clinical research, the wound care nurse responds with a recommendation on the diagnosis, provider treatment and at-home care instructions. Most wound care eConsults include links to references, clinical evidence and patient care instructions. The goal is to treat both the immediate need and prevent recidivism, so the eConsult response provides warning signs that the patient may need to watch out for.

Common Wound eConsults

Lower Extremity Wounds

Since lower extremity wounds are the most common, let’s examine the diagnosis and treatment of poor circulation and venous ulcers.

In the past, a lower extremity problem was often classified as peripheral vascular disease (PVD) and confused with arterial insufficiency. PVD means vascular; patients presenting with lower extremity wounds could be suffering from venous disease or arterial insufficiency. Today, a wound care nurse will distinguish the etiology of a lower extremity wound regarding Peripheral Artery Disease (PAD) and PVD to clarify venous insufficiency.

Is it an acute wound, or is it a chronic wound? 

Acute wounds are trauma-related or surgical incisions. They can often be categorized as” clean wounds” or” clean wounds” that have become contaminated; the latter may need antimicrobial intervention. Trauma-related wounds that require further treatment are commonly seen among patients with comorbidities or complicated wound closure.

Chronic wounds are frequently neuropathic and diabetic foot ulcers, lymphedema or pressure injuries. In the case of pressure injuries, a complicated surgical incision can start as an acute wound and become a chronic wound.

Occasionally, a wound will have a mixed etiology. For example, the patient may have poor arterial flow and venous. In this case, the eConsult response may include additional questions for the PCP to assess the wound adequately or recommend studies to clarify the diagnosis.

Many wounds with mixed-etiology pressure injuries have stable scars. A stable scar, typically a leathery, somewhat hard, is common among bedbound and palliative/hospice patients. Confirming whether the scar is boggy, draining, or inflamed is important. For bedbound and palliative patients, it’s recommended that the PCP include the goals for care in the eConsult request. The eConsult response will focus on the goals for managing the patient’s care.

Stalled Wounds can occur for various reasons, including how the wound is cleansed and the selection of bandage or compression.

Preventing Recurrence

Once the wound is closed, the goal is to prevent recurrence. About 70% of lower extremity wounds are venous insufficiency wounds. Of these, approximately 50% also have a mixed disease component, particularly an arterial component. In other words, the patient has chronic venous insufficiency, plus they do have a PAD component. In this situation, the advice from the wound care nurse will be less aggressive. While compression therapy is a mainstay for venous insufficiency, compression therapy is often conservative for patients with both PVD and PAD to avoid arterial damage.

Venous Wounds Presenting Post-Trauma

When the patient has venous insufficiency of the lower extremity, the wound is sometimes identified as a traumatic injury – bumping a leg, for example. A telltale sign is when the patient arrives at the PCP with a complaint like, “I got this injury about a week ago, and it’s still not getting better.”

Often, patients with venous disease will experience an injury, and the wound will get better. However, patients with venous disease must receive a corrective procedure or pursue lifelong compression therapy to prevent these wounds from becoming recurrent.

Edema is common with venous wounds. It is often located at the gator area of the lower extremity and seen at the medial malleolus, but it can also be lateral or circumferential. If a venous wound also has a posterior lower extremity component, it’s not unusual to see a PAD component.

The management goal is to promote venous return, control the edema and manage that exudate. Venous wounds are usually highly exudative.

Image 1.1 shows the typical configuration of someone with advanced venous disease or venous insufficiency ulcer. It’s a very irregularly shaped wound that is not deep and has different types of wound tissue. These wounds are often yellowish with sloughy or ruddy-looking tissue.

This individual has a very advanced venous disease, lipodermatosclerosis. Lipodermatosclerosis is an inflammatory condition characterized by subcutaneous fibrosis and hardening of the skin.

When treating this patient, it’s important to:

Image 1.1: Venous Wound
Venous Wounds Presenting Post-Trauma
  • Minimize skin irritation.
  • Avoid scented lotions or those that contain.
  • Eliminate infection.
  • Protect the skin from further injury.
  • Stimulate the ingrowth of the healing granulation tissue.
  • Develop a long-term compression plan.

When a mixed etiology is present, the Certified Wound Care Nurse will typically recommend a conservative approach to care. Most eConsults for these conditions include recommendations for both topical therapies and compression.

The eConsult response will reference the appropriate topical treatment for the skin and where the patient or provider can purchase the treatment. The recommendations will vary based on the skin’s condition and the amount of healing. The most common topical recommended in wound care eConsults is Iodosorb (cadexomer iodine). Due to the variety of compression systems available, the eConsult response will frequently include a recommendation of the appropriate system and a video link to demonstrate the proper application and who should apply the compression – provider or patient. A product frequently recommended for compression is the 3M™ Coban™ 2 Two-Layer Compression System, typically applied twice weekly.

Wound Care eConsults: Treating Poor Circulation and Venous Ulcers

Myra Varnado, RN, Director of Wound & Ostomy Services and Wound Care Nurse at Corstrata, discusses the latest wound care techniques with a focus on treatment for poor circulation and venous ulcers.

Myra Varnado, RN, Director of Ostomy Services and Wound Care Nurse at Corstrata, discusses the latest wound care techniques with a focus on treatment for poor circulation and venous ulcers.
In this video, you will learn:
  • Common wound care conditions treated by eConsults
  • Treatment for the onset of venous insufficiency wounds
  • Management of goals for these wounds
  • Discuss a patient case – Persistent venous stasis ulcer now with hypergranulation tissue

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