By Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA

Note From the Editor: This is the second of two articles on maggot therapy. The first article appeared in our July/August 2014 issue, Read part 1 here.

Whether your practice is an acute-care setting, a clinic, home care, or elsewhere, maggot debridement therapy (MDT) can prove to be a useful tool in wound care. But setting up any new program can meet resistance—and if you seek to establish a maggot therapy program, expect to meet significant resistance. By arming yourself in advance, you can achieve your goal more easily. This article covers all the bases to help you get your maggot therapy program off the ground.

Know what you’re getting into

Be knowledgeable. Do your homework and learn all you can about maggot therapy. Know what it can and can’t do, how it works, and the lifecycle of flies and maggots. Learn about the most common complications and how to avoid them.  To gain knowledge, use the wealth of instructional resources in journals, on the Internet, and at conferences. Be aware that the Biotherapeutics, Education, and Research (BTER) Foundation (www.BTER
Foundation.org) has many resources devoted to maggot therapy; most are available for free. You can contact the foundation directly to arrange lectures, workshops, and webinars. Also consider attending a professional wound care conference, such as Wild on Wounds, which usually features a maggot therapy workshop. (See Maggot therapy resources.)

Recruit allies

A common obstacle to an MDT program is inability to find others who want to get involved. But try to get at least one other person on your side (more if possible), and make sure this person is an influential member of the wound care team. The strongest ally may be the head of the wound care or skin integrity team, a surgeon, or the infection prevention officer. These individuals not only can lend support for an MDT program but also fend off such excuses as, “Maggots are an infection risk,” or “The Joint Commission will never approve.” If you don’t reach out to these individuals and convince them of the merits of your vision, the opposition may recruit them to block your efforts to establish a program.

Be prepared

Once you decide an MDT service can yield a net benefit for your facility’s wound care program, you’ll still need to convince colleagues and administrators of its merits. Don’t be scared; be prepared by working out everything in advance. Develop policies and procedures for the use of MDT in wound care. (On the BTER website, registered users can download a policy and procedure template at www.bterfoundation.org/policytemplates.)
Create a plan for patient and therapist education. The BTER Foundation’s patient education brochure “Is MDT for Me?” is a valuable educational resource available on the foundation’s website, along with recorded patient interviews.

Developing a notebook of peer-reviewed clinical studies also can help you prove MDT is effective in treating pressure ulcers, venous stasis ulcers, diabetic foot
ulcers, postoperative ulcers, or other specific conditions. Be sure this notebook includes documents indicating that the maggots your clinic will use are cleared for marketing by the Food and Drug Administration. (The BTER Foundation maintains a library of such literature, available to members.) By addressing these and other likely problems or obstacles in advance, you won’t have to spend the next year searching for solutions.

Be flexible

Ultimately, your MDT program will need to fit into your facility’s wound care program. Prepare for the possibility that your facility might impose certain requirements—insisting, for instance, that your patients be treated as in-patients or that all maggot dressings are applied by medical staff. To get your program off the ground, keep an open mind and consider meeting such requirements and making compromises. Remember: it will be easier to renegotiate for the policies you want once others see firsthand that your program is running well.

Dealing with administrators and the “NIMBY” mindset

Anticipate questions by administrators, and have on hand the data or publications that support your answers. Address the areas of concern to those who are responsible for patient safety, financial solvency, and public relations. Present your plan for patient and staff education and safety.

Many healthcare administrators acknowledge that maggot therapy is effective, safe, and cost effective, but they don’t want it in their facility. This is the “not in my backyard” (NIMBY) mindset. If you don’t have buy-in from the administration, your program will be a nonstarter. So when looking for allies to join your effort, consider approaching a hospital administrator or someone who works closely with the administration, such as a department head (chief of orthopedic, reconstructive, or podiatric surgery), chief of nursing or rehabilitation medicine, leader of the infection-prevention team, or chair of the skin integrity committee. Don’t choose someone you don’t know; instead, select someone you’re comfortable with, who will respect you and listen to you.

To communicate more effectively with administrators, try to see the issue from their viewpoint. Some administrators are concerned about flies getting loose in the hospital, passing the next inspection by The Joint Commission, hospital-acquired myiasis (parasitic infestation), negative media attention, and poor public perception. Be prepared to explain why each of these concerns is unfounded. To do this, perhaps you can arrange a chat between your administrators and an administrator from another healthcare facility that has an MDT program in place. Or ask a maggot-therapy experienced administrator from another facility to write a letter to your administrators. Be sure to emphasize that maggot therapy can bring positive local media attention and decrease costs for inpatients, uninsured patients, and anyone else on a capitated or fixed-fee reimbursement scheme.

You’ll have an easier time getting the administration to sign off on an MDT service if you can demonstrate that maggot therapy is cost-effective and reimbursable. Ask your coding department or maggot suppliers for help in this area, if necessary. You might want to download maggot-therapy reimbursement statements from your facility’s common insurers, or access the reimbursement information available on the BTER Foundation website. The Foundation even provides patient assistance grants for patients without insurance or whose insurance declines to pay.

Recruiting and educating patients

Most wound care patients don’t have trouble accepting maggot therapy—especially those with foul-smelling, draining, activity-impairing, limb-threatening wounds. Many have endured or may be facing surgery or even amputation. For them, wearing a dressing with maggots for 2 days may be no big deal, particularly if they understand the potential benefits.

Play down the negative

One of the keys to interacting with patients successfully is to show you’re comfortable with maggot therapy yourself. Don’t tell a patient, “I know this sounds gross, and you’re probably not going to like what I’m about to suggest, but…” If you do this, the patient is likely to respond, “Maggot therapy? That sounds gross and I don‘t like what you’re suggesting.”

Don’t put a “nonbeliever” in charge of discussing maggot therapy with patients, and don’t give patients the idea that you expect them to find it repulsive. Instead, present the option matter-of-factly or even enthusiastically, as you would any other medical option: “I think maggot therapy might help. Let me explain the benefits, risks, and alternatives.”

Anticipate that most patients will have questions, and be prepared to answer them. (See How to answer commonly asked patient questions.) An effective means of education is to have former MDT patients speak to MDT candidates. A registry of former patients willing to volunteer as educators or interviewees can be a valuable adjunct to your maggot therapy service. Brochures, video testimonials, and other materials also can aid patient education.

A few weeks of solid preparation up front can save you months of drawn-out discussions about the benefits of an MDT program with administrations. Instead, you’ll be able to spend this time providing patients with the benefits of maggot debridement.

Selected references

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2):336-44.

Sherman RA. Mechanisms of maggot-induced wound healing: what do we know, and where do we go from here? Evid Based Complement Alternat Med. 2014;2014:592419. www.hindawi.com/journals/ecam/2014/592419/. Accessed October 5, 2014.

Wayman J, Nirojogi V, Walker A, et al. The cost effectiveness of larval therapy in venous ulcers. J Tissue Viability. 2000;10(3):91-4.

The authors work at the BioTherapeutics, Education & Research (BTER) Foundation in Irvine, California. Ronald A. Sherman is director. Sharon Mendez is a member of the board of directors. Catherine McMillan is a research intern.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.