Equine Wound Center

The idea of wound centers originates from human medicine and started in Denmark. In the nineties, Danish patients with chronic ulcers were gathered in 4 centers spread throughout the country. In these centers, doctors and nurses from various specialist fields but with special interest, knowledge and experience in chronic wound management were collected. Patients and wounds were examined, discussed and treated in a systematical way. Patients and wounds received special attention, treatment was no longer based on a personal preference and opinion, and non-healing was not an accepted outcome. The collaboration of expertise from various disciplines resulted in almost halving healing time, and chronic wounds that had been open for over 25 years healed by this systematic approach.

“Expertise centers result in faster and better healing”

Arch Surg. 2001;136:765-772

• The concept of a wound centre improved healing rates and decreased amputations
• The concept and structure of a wound centre enhanced the knowledge and understanding of wound problems and increase the status of wound healing and patient care
• David R. Knighton 1992: standardizing treatment plans seems to improve healing of certain chronic wounds
• Wound healing education is included to a minor degree in the education of medical doctors
• No line in treatment results in delayed healing

Wound Rep Reg 2003;11:452-457

• Lack of organization seems to be the main problem for wound patients which hinders progress
• Health care delivery by individuals rather than teams is not in the best interest of patients
• Importance of surgical procedures in wound healing and care

Wound Rep Reg 2004;12:129-33

• The organization of a wound team, not the change in products, increases healing of problem wounds

J of Wound Care 2018;27
After the great success of the initial wound centers proving that expertise centers are a huge benefit for the patients, the European Wound Management Association (EWMA) has set up the EWMA wound center endorsement system in order to encourage high quality wound centers. The endorsement system focusses on the minimum requirements of a wound center, which is essential to support standardized, high quality treatment service in the centers and a system to evaluate the quality. Following this idea, the VWHA, in collaboration with EWMA, has set up a similar system for horses with wounds.

Wounds and their treatment face several challenges or difficulties both in veterinary and human medicine. The severity of wounds is often underestimated by owners thinking that they can heal wounds themselves with ‘’help” of social media. Treatment of wounds by veterinarians is often based on personal preference, habits in the practice or clinic and commercial advertisement. Wounds are sometimes treated for long periods without making progress or even without the perspective to heal anyway with or without surgical interference, and oftentimes, a critical evaluation is missing. Research and publications in the field of management of equine wounds are limited, due to a lack of priority given to chronic wounds traditionally from research institutions and founding parties. Wounds are not always seen as interesting by surgeons or specialists because treating equine wounds is time consuming, expensive, can be frustrating and with limited economical revenue, making investment in equipment to treat wounds unpopular. All these factors taken together, leads to equine wound management as a veterinary specialist field lacking behind compared to other fields in veterinary medicine in terms of progress and development, whereas the vast total number of wounded horses world-wide represent enormous welfare aspects for both horses and owners.

“An Equine Wound Center has an expert function: it is a place where interest, evidence-based knowledge, experience and expertise in equine wounds assemble leading to optimal treatment and fast healing”.

Participating EWC is eager to invest in equine wound management in the following way:

• Time: collect, share and spread knowledge
• Priority: team attention
• Money: equipment, facilities, knowledge
• Contact/collaboration with referring colleagues
• Critical attitude: search and discuss options between centres

The aim of an EWC is to offers specialized wound care to equine patients and to make specialized wound care accessible for each horse and each owner in each country. An EWC makes a treatment plan from the start, and if surgery is necessary and predicted, this will be discussed with owners from the beginning as well. An EWC focusses on surgery (delayed closures, reconstructions, Meek grafts) when possible and advantageous to the patient. Surgery limits healing time and prevents long-lasting treatment with bandages. The welfare of horse and owner is always considered: an EWC does NOT treat patients without this perspective.
This attitude will result in faster healing, better results (functional, cosmetic), better revenue per patient and worked hours and satisfied clients.

Equine Wound Centers can solve most of the abovementioned issues of the current situation: healing of wounds can be improved by increasing and centralizing knowledge, by a systematic approach of wounds and their treatment and by offering special surgical options with predictable, reliable and consistent outcomes such as the modified Meek technique and reconstructive surgery. Additionally, the network makes it easy to share knowledge and to discuss cases, and to consult experts from other Equine Wound Centers to ask for advice in case of difficult or complicated wounds so that a well-considered treatment plan can be made from the beginning. This will improve the clinical outcome of wound treatment and result in satisfied clients. It will give confidence to the owner and referring vets. Collaboration with colleagues in the field will unburden them from hard-to-heal patients and they will be open to seek advice. It will stimulate surgery on wounds, more wounds will be referred and patient flow will increase as well as the revenue per patient. It will increase the status of wound treatment making that investment in equipment pays off. In this way we can make progress in the quality of wound treatment and move forward as a profession, whereas collaboration will inspire everybody involved by the discussions and knowledge sharing, and increase the satisfaction of wound treatment.

• Higher quality
• Increased healing rates
• Increased visibility
• Increased patient flow

The VWHA follows the EWMA wound center endorsement system, with the difference that VWHA aims to limit the administrative procedure by combining some of the steps in a practical way.
In brief: the requirements are interest of the staff; facilities; available equipment; and standardized wound treatment and openness to discussion about wounds within the EWC structure. All requirements are listed in the initial application form. Courses/ continuing education have to be planned to ensure standardization of treatment, and 10 surgical procedures on equine wounds are evaluated (5 reconstructive surgeries and 5 Modified Meek grafts).

The process is guided and evaluated by the VWHA council representatives. Following steps are taken:

1. Initial application form
   • Basic info: wound types, numbers, patients reported (short form per patient)
   • Physical facilities: general anesthesia and surgical facilities
   • Procedures and equipment: X-rays, ultrasound, Meek equipment
   • Clinical staff and collaboration: 2 vets and 2 nurses responsible: to warrant continuation
   • Research and education: train colleagues, competence maintained/updated regularly, data collection
2. Review of center data provided via the application form and follow-up dialogue to identify areas of improvement
3. Planning courses for staff and referring vets combined with visit to the wound center. Courses are based on research, physiology, clinical evidence: (also base for VWHA courses), including protocols
   • 1 day: acute traumatic wounds + wetlab
   • 1 day: wounds healing by second intention
   • 0,5-1 day: skin grafting and reconstructions + wetlab
4. Final report and endorsement: acknowledgement of EWC by VWHA council representatives:
   Ten guided or evaluated procedures (5 reconstructive surgeries and 5 Meek grafts on equine wounds) are submitted, using one form for each procedure, and discussed.
5. Re-endorsement every 5 year:
   Overview of patients treated (short form per patient)

Clinics acknowledged as Equine Wound Center and those clinics in the process of being acknowledged will meet twice a year to create a basis for discussion and to share knowledge.

• In person during the annual VWHA conference
• Online in November

During these meetings we share cases and discuss wound problems. The aim is to learn from each other and to optimize wound treatment for the future. In this way a network for collaboration, inspiration, discussion and knowledge sharing is created.

4 Pillars of Equine Wound Centers: KRAC

Knowledge
Resources
Attention
Collaboration