Critical elements to building an effective wound care center

Peter F. Lawrence, MD, Section Editor PRACTICE MANAGEMENT Critical elements to building an effective wound care center Paul J. Kim, DPM, a Karen K. Evans, MD, a John S. Steinberg, DPM, a Mark E. Pollard, MHSA, b and Christopher E. Attinger, MD, a Washington, DC There are a growing number of wound care centers being established globally. The emergence of these centers reflects the increasing incidence and prevalence of chronic wounds as well as the cost to the health care systems these patients represent. A systematic approach to the development and implementation of a comprehensive wound care program is necessary to provide quality wound care as well as to establish a financially viable enterprise. A wound care center can take shape in various forms from small free-standing clinics to large hospital-based programs. Regardless of the physical location, the most important factor for the success of the wound care center is a strong commitment by the members of the multidisciplinary team. The capacity to effectively manage certain wounds can be limited by the absence of key specialties within the team. The physical space and financial support from the sponsoring institution are also important components. This article reviews the critical elements to building and sustaining a successful multidisciplinary wound care center. (J Vasc Surg 2013;57:1703-9.) Wound care has become a prominent field of medicine and surgery. The steady rise of wound centers reflects a trend toward specialized medical and surgical care provided at a single location or institution. This model is not a new concept and was first popularized and promoted in the care of cancer patients. With mortality rates of chronic wounds rivaling that of some types of cancer, this model of a concerted team approach seems most appropriate. 1 In addition, there is a growing incidence of chronic wounds and recognition of the complexity involved in caring for these patients. The prevalence of chronic wounds is estimated at 2% of the US population. 2 Chronic wounds encompass a vast array of etiologies including trauma, diabetes, venous disease, ischemia, pressure, infection, autoimmune diseases, and coagulopathies. 3 Caring for each wound type requires varying expertise with unique treatment requirements. The unfortunate sequelae of untreated, delayed, or inappropriate wound care can be amputation, which can occur at rates exceeding 60% and From the Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University School of Medicine, a and Hospital Administration, b MedStar Georgetown University Hospital. Author conflict of interest: none. Reprint requests: Christopher E. Attinger, MD, Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, Georgetown University School of Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, Washington, DC, 20007 (e-mail: cattinger@aol.com). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.11.112 add to the over health care cost burden. 4-6 This has led to the development of a comprehensive and systematic approach that includes working as a team, specialized personnel, facility resources, and financial commitment. 7 This article is based largely on our experience over the last 15 years in building a tertiary care academic-based wound center focused on limb salvage and contains the biases inherent therein. However, we have tried to balance that experience with an extensive knowledge and familiarity with large chain-run community-based wound centers. ORGANIZATIONAL STRUCTURE Wound centers are organized in a variety of ways and can be free-standing clinics, housed within community hospitals, or at an academic medical center (Table I). 8 In today s practice, many wound centers are part of a regional health care system or a national health care management group. These wound centers are staffed with a hybrid of part-time and full-time providers and support personnel. Dedicated administrators oversee daily operations with billing departments ensuring proper documentation and quality control. The vast majority of wound centers include private or independent health care providers that work one-half to 2 days per week in the wound center and bill independently for the services they provide while the facility bills a separate facility fee. An example of this model is Healogics (Jacksonville, Fla), which is a national chain of wound centers predominantly based within community hospitals. Healogics provides staff, administrative support, training, advertisement, clinical practice guidelines, and specialized electronic medical records (EMRs) that include 1703

1704 Kim et al June 2013 Table I. Comparison of wound care center models Free-standing clinic Community hospital Academic hospital Advantages Proximity to the patient s residence Easy access into the building Proximity to the patient s residence Unintimidating setting/size Some ancillary services available Centralized location for all health care needs Shared EMR Easy communication between specialists Ancillary services available Tertiary care Scholarly atmosphere The use of novel technologies/devices/drugs Rapid admission and operative capabilities Participation in investigator-initiated and sponsored clinical trials Disadvantages Limited on-site ancillary services Lack of regular and consistent communication between providers Lack of tertiary care Lack of a scholarly atmosphere Not all providers have offices/clinics housed within the hospital Difficult access to immediate care due to large patient volumes Large complex campus EMR, Electronic medical record. database management that incorporates evidence-based algorithms. For the services they provide, they receive a prearranged amount for every patient visit. For health care systems or health care providers that lack experience and expertise with administration of wound care programs, this type of turn-key wound care model can be a preferred option. There are fewer wound centers that employ full-time health care providers and support staff dedicated solely to wound care with an integrated approach to inpatient and outpatient wound management. Typically, these wound centers are tertiary referral institutions housed within an academic medical center with a team of providers that have expertise in the medical and surgical management of this patient population. These institutions can address all types of wounds or specialize in certain areas such as limb salvage or pressure ulcers and focus on these more complex wounds in patients with multiple comorbidities. Members of the provider s team include many different specialties, which can include vascular surgery, podiatric surgery, plastic surgery, orthopedic surgery, infectious disease, general surgery, rheumatology, hyperbaric medicine, hematology, endocrinology, hospitalist, physiatrist, nurse practitioner etc. The major advantage of this model is that it is easier for members of the wound care team to develop a cohesive plan and to be in constant communication with one another because they are all co-located. This avoids the potential silo effect of having multiple health care providers with private offices working relatively independent of one another and dedicating only a portion of their time to wound care (eg, community hospital-based wound center). Furthermore, the co-located physician model offers fluid and seamless care from the clinic, in-patient admission, operating room, postoperative stay, and discharge. 7,9 Despite these advantages, a comprehensive limb salvage center is difficult to organize, manage, and maintain without the full support of the hospital administration. The expense of this endeavor can be a significant ratelimiting factor with tight profit margins attributable to large overhead costs inherent to large academic institutions. However, the outpatient expenses of these types of centers must be balanced with the downstream revenue generated from use of hospital resources such as admission, use of diagnostic testing, dialysis, operating rooms, intensive care, etc. as well as consults for physician services from various departments. Hyperbaric oxygen (HBO) has had a colored history in the setting of wound care due in large part to the paucity of level-one evidence for its use. 10 However, it has been shown to be effective in the setting of radiation injuries, osteoradionecrosis, osteomyelitis, threatened flaps, and diabetic ulcers. 10 Most wound centers end up referring 12%-15% of wound care patients for hyperbaric treatments to address wounds recalcitrant to conservative care or to prepare wounds for surgical treatment (ie, radiation). If the transcutaneous oxygen measurement around the wound is too low for healing but rises significantly during an oxygen challenge, there is a significant chance that the HBO treatments can be a useful adjunct to wound care. 11 It can be a useful adjunct in the treatment of many complex wounds. Research is another important aspect of a wound center. In particular, a wound center housed within an academic institution fosters a culture of investigation, encourages an environment of perpetual learning, and stimulates discussion among the wound care team. The infrastructure necessary to develop and execute research is readily available in this setting. Research can take the form of translational research, investigator-initiated clinical studies, or sponsored clinical research trials. An academic institution promotes collaboration with bench scientists in translational research. Sponsored clinical research trials can potentially become a revenue stream for the academic institution that houses the wound center. Research enables

Volume 57, Number 6 Kim et al 1705 the exploration of new drugs, devices, or techniques that may potentially lead to improved and more predictable clinical outcomes. MULTIDISCIPLINARY PERSONNEL The multidisciplinary approach to wound care is the most important element to the success of a wound care center because no single health care provider is adequately equipped with the knowledge, skill, and experience to provide comprehensive care for complex wounds. Confounding elements include immune/protein deficiencies, coagulopathies, arterial/venous compromise, medical comorbidities, peripheral neuropathic states, infectious conditions, and biomechanical abnormalities. Superimposed on these elements are psychological and socioeconomic considerations including transportation issues, the lack of a social support system, and stigma of a chronic wound and/or amputation. The multidisciplinary approach to wound care has resonated and has led to a greater than 50% improvement in outcomes by reducing both amputation rates and wound related complications. 4,12-23 The members of the multidisciplinary team reflect the different pathologic processes involved in chronic wounds with each member playing an important role in the healing process. This includes physicians, nurse practitioners, physician assistants, physical therapists, nutritionists, wound nurses, orthotists/prosthetists, social workers, medical assistants, and administrators (Table II). The initiation of a wound care program involves bringing together core members of the team. At a minimum, a single physician needs to be the champion for the wound program at its inception. Specialists are then recruited into the core group as the wound center grows and often includes plastic surgeons, podiatric surgeons, vascular surgeons, general surgeons, orthopedic surgeons, and wound care nurse practitioners. Nonsurgical specialists in this core group can include internal medicine, dermatology, endocrinology, rheumatology, infectious disease, hematology, and/or emergency room physicians. A physician with surgical training brings an added dimension of offering both conservative and surgical treatment options. We have averaged approximately 1500 combined inpatient (2/3) and outpatient (1/3) surgical cases per year over the past 5 years. We have also found that by increasing the number of specialty providers, there was a direct increase in the overall patient volume (Fig). Our multidisciplinary model includes plastic surgery and podiatry at its core, whereas other such centers have used podiatry and vascular surgery at its core (eg, toe and flow model ). 8 This reflects the need for personnel whose training and expertise include soft tissue reconstruction, revascularization, and correction of biomechanical problems in lower extremity limb salvage. The role of vascular surgery is critical to the limb salvage effort and very close collaboration with this service has been a larger reason for our success. Every patient gets an angiosome-directed vascular examination with a handheld audible Doppler. They are referred to vascular surgery if there is any concern about the quality of blood flow. Our concerns and goals for salvage are detailed in the consult (eg, angiosome-directed revascularization, type of revascularization etc) and a conference is held post-vascular evaluation. The patient is transferred to the vascular surgery service for the revascularization portion, while the wound team continues to care for the wound. Once revascularized, the patient returns to the wound service for completion of his or her wound care, reconstruction, or partial or full amputation. This clinical course enables the vascular surgeon to focus solely on revascularization with the knowledge that it will not be compromised by poor or inadequate wound care. In the postoperative course or long-term follow-up, vascular re-evaluation occurs if the wound deteriorates for unclear reasons. If a patient with a wound is first encountered by vascular surgery, the wound team is consulted during that visit, and admission is coordinated so that appropriate wound care can be delivered pre- and postrevascularization. The wound team will continue to manage the wound until it is healed. This protocol has ensured that the vascular surgeon is far more likely to get quality referrals that require revascularization because the wound service acts as an effective screening tool. A referral/consultation pattern with all the other specialists also supplements the core group by adding their expertise to the wound care center. Each specialist should be selected based on their level of experience and interest in patients with chronic wounds. There is a clear advantage to wound centers that have these specialists housed within the same hospital. A common infrastructure provides for shared resources (eg, EMRs) and rapid internal referral patterns. Further, the probability of daily interaction through multidisciplinary grand rounds and other opportunities lends itself to better patient care within a collegial environment. If the patient is admitted to the hospital, these same individuals who were providing the outpatient care can continue to provide inpatient care and coordinate the process through consultative services. Other members of the wound care team include nursing and other support staff. Wound care is a timeand work-intensive process with each patient taking 45 to 60 minutes per outpatient encounter. While the provider s interaction may be limited to 10 to 15 minutes, much of the work is conducted when the provider is not in the treatment room. The initial work by the nurse and/or the medical assistant includes placing the patient into the treatment chair, obtaining vital signs, updating the general medical condition and medications (this process is more time intensive if this is a new patient), removal of dressings, cleansing of the wound, and photographing the wound. The provider then will review the history, examine the wound (including taking measurements), perform a debridement if necessary, review any relevant studies, and recommend a treatment plan. The nurse and/or medical assistant will then implement the treatment plan, re-dress the wound, and finally assist the patient in exiting the

1706 Kim et al June 2013 Table II. Members of the multidisciplinary clinical team Member Plastic surgeon Podiatric surgeon Orthopedic surgeon Vascular surgeon Infectious disease specialist Endocrinologist Hospitalist Internal medicine Rheumatologist Hematologist Psychiatrist Hyperbarist Interventionalist (radiology, cardiovascular) Nutritionist Physical therapist Orthotist/prosthetist Wound nurse Medical assistant Nurse practitioners/physician assistant Anesthesiologist Surgical technician Contribution Soft tissue reconstruction and coverage Wound care and surgical biomechanical management Lower extremity skeletal reconstruction Vascular assessment and open and endovascular intervention Medical infection management Aggressive glucose management Acute inpatient management Medical management of comorbidities Vasculitic and autoimmune processes Coagulopathy components Behavior modification and psychological assessment HBO therapy Assessment and endovascular intervention Optimization of healing potential through counseling and supplementation Rehabilitation and mobility training Orthotics, prosthetics, bracing Wound care and patient education Casting and dressing application Pre- and postoperative care, wound care, discharge planning, and patient education Anesthesia induction in high-risk patients Knowledge of equipment/supplies HBO, Hyperbaric oxygen. Fig. This chart reflects inpatient (as the primary admitting team and consultations) and outpatient clinic visits by providers of the MedStar Georgetown University Hospital Center for Wound Healing and Hyperbaric Medicine. Initially, a single plastic surgeon provided all of the wound care within the hospital from 1999 to 2004. In 2004, a podiatrist was added as a provider. In late 2010, a second podiatrist was added as a provider along with the opening of hyperbaric chambers. In 2012, a second plastic surgeon was added as a provider. Note the marked increase between 2007 and 2008, which reflects the opening of a designated space within MedStar Georgetown University Hospital. Prior to this, the wound center space was shared with another specialty. The 2012 numbers are based on one-half year projections. The y axis reflects numbers in the thousands. The x axis reflects fiscal year dates 1999-2012. This information was derived from evaluation and management billing codes. treatment room. An additional component of the clinic visit includes time for patient education that can aid in patient compliance with the treatment plan. There is further work conducted by the nursing or support staff after the patient has left the clinic including coordinating referrals, laboratory and radiographic tests, and coordinating home nursing wound care. On the inpatient side, it is helpful to have both an inpatient nursing floor and operative staff that are familiar with the care of the patient with a chronic wound. If the patient requires admission, it is helpful that he or she be placed on a floor dedicated to wound care so that the nursing personnel are thoroughly familiar with wound care dressings. The wound care center can facilitate the inpatient stay by providing nurse practitioners or physician assistants who can provide education, medical management, help with discharge planning, and follow-up. We have also found that having hospitalists provide medical care for our patients has decreased the complication rate by half because of improved medical management (cardiac and respiratory optimization, tighter glucose control, etc). Given the financial impact of efficient discharge planning, it is critical to implement timely transition to an outpatient setting (eg, rehabilitation facility) and coordinate readmission for staged procedures at the time of admission. Having one or more operative rooms exclusively dedicated to wound care patients helps address the emergent nature of most wounds in a rapid and efficient manner. In addition, a dedicated anesthesiology team and operative staff, familiar with wound care patients, increases safety, diminishes cancellations, and decreases operative time. Our comprehensive integrated approach to a patient with a chronic wound may include all of the individuals discussed above at some point in the patient s care. For example, many patients initially present to the emergency department with a grossly infected limb. The patient is subsequently admitted to the hospital by the internal medicine service or directly to our service. If the patient

Volume 57, Number 6 Kim et al 1707 is admitted to our service, a hospitalist is immediately involved in the medical management of the patient. The infectious disease service is then consulted for antibiotic therapy recommendations. If there is a question of ischemia, the vascular surgery service is consulted to further assess the patient s peripheral perfusion and implement a plan to maximize arterial flow to the limb. In emergent cases, either the plastic surgeon or podiatric surgeon will initially decompress the infection prior to vascular intervention. We then institute a staged surgical approach to limb salvage in which the patient may return to the operating room on several occasions until the wound is deemed ready for closure. Orthopedic surgery may also be consulted at this point to provide external fixation to stabilize the limb or protect the closure or coverage. Finally, either the plastic surgeon or podiatric surgeon will perform the definitive closure/amputation procedure prior to discharge. Physical therapy will then assess the patient for suitability for discharge to a particular facility. A prosthetist may be involved at this point for prosthesis/orthoses management as well as the dietician who recommends dietary changes. Our discharge team coordinates rehabilitation placement as well as coordinates medications and follow-up in the clinic. The patient is then followed in our clinic by the plastic and/or podiatric surgeon. Coordination and communication of the patient s care continues with the vascular surgery service as well as the other appropriate services (eg, infectious disease, rheumatology) who were involved in the patient s inpatient care. This integrated, comprehensive approach involving a multitude of individuals has made our limb salvage service successful. Administrative support is critically important to the longevity and financial viability of the wound center. At a minimum, administrative staff within the wound center should include a clinical director, clinic administrator, and a nurse manager. The clinical director is typically one of the providers with the added responsibility of overseeing all clinical activities as well as the overall growth of the wound center including outreach and advertising. The clinic administrator is responsible for the business aspects of the wound center pertaining to budgets, billing issues, capital expense purchasing, regulatory compliance, and day-to-day operations. The nurse manager is responsible for human resource issues for support staff and the dayto-day clinical operations including staff and resource allocation. The nurse manager is the heart of the operation with an eye toward providing quality patient care as well as maintaining staff morale. FACILITIES There are some basic necessities pertaining to the physical space needed to house a wound care center. The parking lot should contain ample handicap spaces with easy access to the building. The building should include wide hallways and elevators to accommodate wheelchairs, stretchers, and walkers. The waiting room should accommodate these assistive transportation aids. The number of treatment rooms should reflect the number of providers staffed for that day. For example, three to six treatment rooms are necessary for a single provider with patients scheduled every 15 to 30 minutes; this will enable the provider to see between 15 and 24 patients in one-half day clinic session. The rate-limiting step for increasing patient capacity is space and staffing due to the time that is required for each patient visit. If expansion of the number of rooms is planned, then proportional increase in staffing is necessary to support this growth. Other practical requirements such as ceiling-mounted swing arm lights and examination chairs that have the capability to rise and tilt allow for a thorough examination and comfort for the patient. In addition, if patients with decubitus wounds are to be seen, patient hoist devices (such as Hoyer lifts) should be considered in the clinic space. Finally, ample storage space is required for dressings and instruments for clinic procedures. Ideally, a wound clinic is housed within a hospital because it allows for easier access to commonly utilized ancillary services such as radiology, phlebotomy, and pharmacy. Further, the chronic wound patient with multiple comorbidities can receive all of his or her medical services in one location because his or her care requires close follow-up with different specialists. The ability to optimize the patient s medical condition becomes increasingly important if patients are undergoing complex reconstructive procedures in the operating room. As mentioned above, this plays a key role in decreasing medical and surgical complications and helps shorten hospital stay. Technology also plays an important role in a wound center. EMRs allow for quick access to the patient s medical and surgical history, medications and allergies, laboratory values, pathology and radiology reports, progress notes, electronic prescription writing, patient scheduling, and billing. Further, a hospital-based wound center most often is a part of the EMR that other services utilize with a shared patient record and is critical for effective communication between health care providers. There are also wound-specific EMRs that can be incorporated into existing outpatient EMR systems that include wound treatment algorithms with benchmark reminders, allow for embedding of photographs, as well as tracking of wound measurements. They can track the wound care team s effectiveness in wound healing to national benchmarks and help to correct deficiencies that may exist. These systems can also track referring physicians and allow for continual seamless communication with them. Most wound center EMRs are designed for wound centers within community-based hospitals. They are based on the financial model of repeated weekly visits where minor procedures and various topical treatments are the primary mode of treatment. There is no room in the algorithm for surgical solutions or referrals to tertiary wound care centers when routine wound care have failed or were inappropriate. This is currently being recognized by the large wound care EMRs and should be addressed in the near future.

1708 Kim et al June 2013 Our wound center incorporates many of the facility requirements that allow us to see a large volume of patients while providing quality care. Our center is located on the first floor of our hospital that allows for easy access. Our hallways are large with ample waiting room space. We have 11 treatment rooms along two hallways with an embedded radiology suite, which allows us to have two providers running clinic simultaneously. Each room contains an adjustable treatment chair and ceiling-mounted lighting. Further, each room contains a computer station with access to the hospital-wide EMR system with modifications specific to wound care. FINANCES There are significant costs associated with taking care of chronic wounds of the lower extremity. The direct health care costs for a diabetic foot wound range from $3096 to $107,900. 24-26 The majority of the costs incurred in the treatment of wounds are facility-related fees compromising 30% of the total direct cost. 27 In the current environment of reimbursement reductions, profitability of a wound center is not guaranteed. On average, an outpatient wound center only collects 33% of billable charges. In fact, the financial goal for a wound center is generally to be budget neutral. There are large overhead costs including personnel, space, and supplies/equipment. In addition, there are hospital indirect costs, which pay for security, heating/cooling, cleaning, debt reimbursement etc. that double the direct cost of the center. Continued hospital or health care system support is further garnered by downstream revenue generated through the use of ancillary services and referrals to specialists within the health care system. HBO therapy can also help defray the direct and indirect costs of a wound center. Despite capital expenses as well as personnel, the use of HBO ultimately contributes to the overall revenue and helps cover indirect costs. Further, inpatient stays and surgical cases from wound care/limb salvage patients provide added downstream revenue outside of the walls of the wound center. These in-hospital billable items are of key financial importance since the hospital generally collects 67 cents of every dollar for inpatient care. The exact amount of the downstream revenue generated is not easily captured because hospital financial databases have difficulty breaking out specific reimbursements within a lump payment for a given patient. Within the wound center, there are generally two types of fees that are incurred: facility and professional fees. The facility fees encompass all fees not captured by the professional fees. For the provider, the fees are 28% lower than they would be in the private practice office setting because the provider does not have to pay for overhead involving space, supplies, staff, and office management. However, the physician s revenue stream is further supplemented by hospital admissions, consultations, and surgical fees. The advantages of practicing in a hospital setting easily offset the decrease in professional office reimbursement rates and make the wound center a successful workplace for the provider. CONCLUSIONS Providing quality wound care is a complex orchestration of structure, expertise, facilities, and finances. Careful consideration of all these factors ensures the appropriate and efficient use of health care dollars and can maximize the probability of a positive clinical outcome for the patient. The ideal wound center model within a regional geographic area involves a community-based wound care center that treats routine wounds and refers unresponsive complex wounds to a central tertiary limb salvage facility with multidisciplinary operative capabilities. In this way, most wounds can be managed effectively with easier access to regular wound care by the patient without overloading a single facility. However, this model is contingent on the prompt recognition by the community-based wound center that more advanced therapies may need to be employed. As wound centers continue to grow in popularity, a comprehensive team approach with appropriate networking, EMR, and a sound business model can increase the odds of a successful outcome. AUTHOR CONTRIBUTIONS Conception and design: PK, KE, JS, CA Analysis and interpretation: PK, KE, JS, MP, CA Data collection: PK, KE, JS, MP, CA Writing the article: PK, KE, JS, MP, CA Critical revision of the article: PK, CA Final approval of the article: PK, CA Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: CA REFERENCES 1. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetesrelated wounds and amputations worse than cancer? Int Wound J 2007;4:286-7. 2. Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen 2009;17:763-71. 3. Shanmugam VK, Tsagaris KC, Attinger CE. Leg ulcers associated with Klinefelter s syndrome: a case report and review of the literature. Int Wound J 2012;9:104-7. 4. Larsson J, Apelqvist J. Towards less amputations in diabetic patients. 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