Tips on Starting a Wound Care...

Tips on Starting a

Wound Care CenterRobert B. McLafferty, M.D., M.B.A.

Chief of Surgery

Veterans Affairs Medical Center

Professor of Surgery

Division of Vascular Surgery

Oregon Health & Sciences University

Portland, Oregon

Disclosures

Medical Director

OHSU Wound & Hyperbaric Center

Course Director:

Modern Wound Care Management

Starting a Wound Care Center

Case Presentation: 53 year-old female

• BMI = 46

• Working full-time

• 5 year history: severe circumferential deep necrotic ulceration of the left ankle/calf area

• Consulted with many physicians

• Edematous/weeping/cellulitic

• Negative venous reflux on duplex, - DVT


The Stereotypes

• Made up of “reject” doctors who have no idea what they are doing

• Have armies of wound nurses who cling to every type of bazaar goo, gel, and bandage –with no proof of beneficial effects

• Hyperbaric Oxygen Therapy is hocus pocus

• No difference in outcomes with my “wet to dry dressing”

• Are more about financial gain than putting patients first


• Vascular Surgery?

• Plastic Surgery?

• General Surgery?

• Trauma Surgery?

• Vascular Medicine?

What Specialty Sees the Most CHRONIC Wounds?

• Dermatology?

• Infectious Disease?

• Podiatry?

• Emergency Medicine?

• Family Medicine?


“Average” Vascular Surgeon Commonly Sees…

• Ischemic wounds

• Diabetic wounds

• Venous wounds

• Surgical wounds

• Pressure wounds


“Average” Vascular Surgeon who cares for wounds…

• Is not part of a wound care center

• Patients with wounds are mixed with other non-wound patients

• Sees their wound patients every two-six weeks

• Does not have specifically trained staff

• Challenging to coordinate SNF/Home care

• Only the very basics of wound supplies in their clinic


Why Create a Wound Care Center…

• Advantages

– Patient centric

– Multidisciplinary

– Evidence-based

– Latest advances applied

– Outcome tracking

– Doctor convenient

– Fiscal accountibility


• Improved efficiency for your clinic/hospital

– Wound patients are very time consuming

– Moving patients frees up clinic time

– Difficult to meet supply needs for wound patients

– Decreases burden to staff

– Patients more comfortable due to specialized area

– Decreasing ED visits

– Decreasing wound problem admissions

Reasons to Move Wounds Out of “Regular” Clinic


Indirect Benefits

• Other benefits− New portal for referrals

− New physician relationships

− Contacts with other ancillaries in hospital

− Multidisciplinary movement of patients

− Central VNA, SNF, LTAC management

• Hospital “indirects”− Laboratory testing

− Imaging testing

− New specialist referral


The “Basic” Algorithm to Heal a Chronic Wound

• Assure adequate arterial perfusion

• Eliminate edema

• Debridement necrotic tissue

• Rx bioburden-film/infection

• Assure off-loading

• Optimize the wound bed

• Apply adjuvant techniques

• Optimize host factors

• Pain control

• Rx “procedural” pathology


Exam/Procedure Room


Power of Serial Debridement

• Standard issue: each exam room− Scalpels

− Forceps

− Scissors

− Curettes

− Snippers

− Ronjeur

− Nail clippers

− Punches (Bx)

− Silver nitrate

− Cautery pencil

− Gauze

− Local anesthetic

− Lidocaine

− Pressure dressing


More frequent visits to wound care clinics result in

faster times to close diabetic foot and venous leg ulcers. Warriner, et al., Advances Skin Wound Care 2012:25:494

• 9 wound centers: 2009 and 2010

• 206 DFUs and 216 VLUs

• One or more weekly vs. biweekly

• Comparison groups similar in demographics

• DFUs mean time to heal: weekly visit group - 22.86 days;

biweekly: 70.63 days (p< .000001)

• VLUs mean time to heal: weekly visit group - 22.15 days;

biweekly - 77.09 days (p < .000001)

Power of Serial Debridement


Debridements

Compression and

Wound Care

Advanced Wound Care

Skin Substitutes

Apligraf

Dermagraft

Wound Vac

HBO

Other Accessories


Reimbursed Indications

• Diabetic lower extremity wounds

• Delayed radiation injury

• Refractory osteomyelitis

• Compromised skin flaps and grafts

• Radionecrosis

• Critical limb ischemia (no options)

UHMS Approved Indications• Air gas embolism• Decompression illness• CO poisoning• Necrotizing infections• Crush injury• Ischemic skin flaps• Severe Blood loss• Avascular necrosis

Outpatient Indications for Hyperbaric Oxygen


• Physical plant design

• Staffing and training

• Supplies, HBO, maintenance

• Physician recruitment/management

• Documentation abilities

• Care algorithms/clinical guidelines

• Billing/accounting/reimbursement

• Market research/practice growth

• Outcomes follow-up/Metrics

What’s Required?… A Business Plan


Physician/Allied Health Prof.

Wound Care

Company

Hospital

Wound Center

A Model That Works…


• Patient centric

– Care coordination

– Supplies/equipment

• Multidisciplinary

• Staff training

• Evidence-based

• Outcome tracking

– Continuing reviews

– Benchmarks to meet

Benefits Contracting with Third Party

• Fiscal transparency

• Unique EMR

• Contracting leverage

• Research advantages

• Increased accountability

• Doctor/staff convenient

• Other “perks”


The Four Hour Wound Center Clinic for the Doctor• 15 patients scheduled for wound clinic

• Four patients in HBO

• Billing RVUs

− 15 Evaluations/mgmt 9.30

− 7 Debridements 9.06

− 4 HBOs 13.6

− 2 Parings 1.22

− 3 Nail debridements 1.40

− 1 Apligaf 10.14

TOTAL 44.72

Open repair of ruptured AAA: 42.00 RVUs


Case Presentation: 53 year-old female

• 5 year history: severe circumferential deep necrotic ulceration of the left ankle/calf area

• Presented to wound center

• Admitted hospital

• STSG at day 7

• SNF (4 weeks: wound center nurses managing)

• Healed with continued Prophore

• Weekly visits for 8 more weeks

• Prophore transitioned to circaid


• May 2013: Initiated concept to OHSU hospital

leadership

• Dec 2013: Grand Rounds –Benefits of Wound

Center

• 2013-14: Lobbied/foster Healogics, Inc. partner

• 2014-16: Contract signed/Architectural planning/

Construction/Hiring/Purchasing/Oper-

ational planning

Dec 12, 2016: Grand Opening!

OHSU’s Journey


OHSU Wound and Hyperbaric Center


• Improve wound healing percentage

• Faster healing rates

• Fewer wound recurrences

• Lower incidence of complications

• Improved physical and emotional wellbeing

• Enhanced education and self care skills

• Improved quality of life

• Improve palliative care of wounds

• Empowered and happy physicians and staff

• Decreased cost

In Summary: It Really is About the Patient…

Thanks!


Tips on Starting a Wound Care...

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