Vol.8 Issue 5 May 2011 www.healthcareledger.com More People with Cancer Are Living Longer Elderspeak: Now Listen Honey! : B th rin e gi co n m gh f e y (4 o orta alt 1 3 ur b h ) 5 h le ca 62 om se re -7 e tti int ng o 04 9 of Wound Care Delivery at Select Facilities
CoverStory Respondents Richard Basile, MD (Photo Right) Medical Director Center for Wound Care and Hyperbaric Medicine, Berkshire Medical Center Pittsfield, MA Raymond Dunn, MD Wound Center Director UMass Memorial Medical Center Worcester, MA Charlotte Langlois, RN Wound Care Specialist Holyoke Medical Center Holyoke, MA Fast Facts Chronic nonhealing wounds represent a significant burden to patients, health care professionals, and the U.S. health care system, affecting 5.7 million patients in the United States and costing an estimated 20 billion dollars annually. The most commonly treated chronic wounds are classified into three categories: venous stasis ulcers, diabetic ulcers, and pressure ulcers. Select health care facilities across the Baystate are focused on providing the highest level of hospital-based wound care services, including the Center for Wound Care and Hyperbaric Medicine, Berkshire Medical Center, Pittsfield, MA; the Wound Center, UMass Memorial Medical Center, Worcester, MA; and Holyoke Medical Center in Holyoke, MA. 4 Healthcare Ledger Healing in Massachusetts: Wound Care Delivery at Select Facilities By Richard Callaway, MD T he proper care and treatment of both acute and chronic wounds has long been a challenge to health care practitioners. Over the last several years, significant advances have been made in the understanding of factors that both facilitate and impair wound healing, accompanied by the emergence of new therapeutic products, concepts, and modalities for optimizing the management of chronic wounds while reducing wound healing time.1 Chronic nonhealing wounds represent a significant burden to patients, health care professionals, and the U.S. health care system, affecting 5.7 million patients in the United States and costing an estimated 20 billion dollars annually.2 The most commonly treated chronic wounds are classified into three categories: venous stasis ulcers, diabetic ulcers, and pressure ulcers, although there are several types that do not fall into a specific category, such as nonhealing surgical wounds and chronic wounds, May 2011
Charlotte Langlois, RN Wound Care Specialist Holyoke Medical Center Holyoke, MA Raymond Dunn, MD Wound Center Director UMass Memorial Medical Center Worcester, MA Richard Basile, MD Medical Director, Center for Wound Care and Hyperbaric Medicine, Berkshire Medical Center Pittsfield, MA resulting from radiation or ischemia. 3 Select health care facilities across the Baystate are focused on providing the highest level of hospital-based wound care services, including the Center for Wound Care and Hyperbaric Medicine, Berkshire Medical Center, Pittsfield, MA; the Wound Center, UMass Memorial Medical Center, Worcester, MA; and Holyoke Medical Center, Holyoke, MA. Although these facilities share a fundamental objective of optimizing wound healing, they are each unique in terms of their organizational structure and approach in accomplishing this objective. This discussion examines how these select facilities in Massachusetts provide wound care for various types of chronic wounds by using established fundamentals of wound care in concert with emerging therapeutic concepts and modalities. The Wound Center: Logistic Benefit According to Richard Basile, MD, Medical Director, Center for Wound Care and Hyperbaric Medicine, Berkshire Medical Center, Pittsfield, MA, the emergence of wound care centers across the United States is a fairly new concept that has been driven by an increase in the number of chronic or late healing wounds in an aging population where diabetes and obesity are reaching epidemic proportions. Basile explains, There has been a dramatic improvement in the logistics and technology of wound care delivery over the past decade driven in part by the economics of supply and demand, and the fact that as the population gets older and is less mobile because of obesity or neurological problems, these patients are very difficult to treat in the private practice setting. As a surgeon for many years in private practice, I have witnessed firsthand the great benefit of wound care centers for patients with wound care needs. Basile continues, Although there have been many advances recently in wound care technology that have demonstrated benefit in treating chronic wounds of various types, adequate wound care still requires the delivery of the fundamentals necessary for wound healing, such as debridement, or the removal of damaged, dead, or necrotic tissue, and frequent dressing changes, which are labor intensive and require more visits than are practical in a private office setting. Multidisciplinary Approach to Wound Care Basile emphasizes that a multidisciplinary approach, involving various clinical specialties, in the hospital is the key to optimize healing in patients with different types of chronic wounds. We treat a number of different types of wounds at Berkshire, including arterial ulcers, venous stasis ulcers, chronic wounds related to diabetes, including diabetic foot ulcers and pressure ulcers, as well as a fair number of nonhealing surgical wounds. For this reason, a multidisciplinary approach is necessary to satisfy the spectrum of resources required for adequate wound care. Basile explains, For example, the diabetic foot ulcer presents the most simplistic, yet 6 Healthcare Ledger May 2011
difficult to achieve mechanical issue, namely what is known as offloading, or the removal of pressure from the diabetic ulcer through braces, properly fitting shoes, or other devices. For these patients, we are fortunate to have access to a wide range of specialists, including primary care physicians, endocrinologists, infectious disease specialists, orthotic Chronic nonhealing wounds represent a significant burden to patients, health care professionals, and the U.S. health care system. specialists, and podiatrists to provide offloading solutions. In addition, all of our nurses have expertise in wound care and are either certified or in the process of becoming certified. So a multidisciplinary approach is key to good wound care practices and fundamental to the whole program. Raymond Dunn, MD, Wound Center Director at UMass Memorial Medical Center, Worcester, MA, and a plastic surgeon, echoes Basile s emphasis on the importance of a multidisciplinary team of specialists in achieving optimal outcomes in wound healing. Good wound care is multidisciplinary. We see all types of chronic wounds in our facility and use all of the advanced wound care products, such as the absorptive adjuncts, silver impregnated dressings, the plateletderived growth factor gel becaplermin, and the collagen and living bilayered skin constructs, emphasizing the basic fundamentals of wound care with surgical debridement and also grafting every time these interventions are deemed necessary for adequate wound healing. Dunn continues, Wound care at UMass Memorial is delivered through the Wound Center by a team of plastic surgeons who provide the latest surgical techniques, including surgical debridement and reconstruction, using grafts, flaps, and microsurgical interventions. In addition the center provides conservative management and treatments that rely on specialists and nurses with wound care expertise. These multidisciplinary teams set up rigid protocols to follow a wound patient through the healing process. Comprehensive Inpatient Wound Care Services Comprehensive inpatient wound care services play a vital role in providing care to patients with chronic wounds within hospitals. Such a program is directed by Charlotte Langlois, RN, Wound Care Specialist at Holyoke Medical Center, Holyoke, MA. Langlois coordinates all aspects of wound care within Holyoke Medical Center. My principal responsibilities include evaluating chronic wounds on admitted patients, performing risk assessment on these patients to determine pressure ulcer risk, implementing protocols to prevent the development of pressure ulcers, and ensuring that all wound care policies are being properly implemented in patients who have wounds needing attention and in patients at risk for developing pressure ulcers. Langlois continues, Although Holyoke has no separate wound care center, there is excellent care provided on the floors by nursing staff who are highly skilled in identifying potential risks in patients, dressing and redressing wounds as necessary and communicating the need for multidisciplinary teams to enter into the wound care process as needed. According to Langlois, this multidisciplinary approach to wound care is as crucial to patients within the hospital as it is in outpatient centers. In addition, emphasis is placed on anticipating the development of pressure wounds in patients who experience repeat admissions or prolonged hospital stays. Our floor nurses at Holyoke play a key role in providing high-quality wound care and regularly consult with me on the status of a patients wounds, which enables me to coordinate their care and course of treatment. Combining Wound Care Fundamentals with Emerging Technology According to Basile and Dunn, the development of a number of advanced wound care products and technologies in recent years has been encouraging; however, they agree on the importance of applying basic principles of wound care to achieve good outcomes. Both Basile and Dunn cite the use of advanced wound dressings in the realm of bioactive wound healing and technologies that promote wound healing through the use of living-cell constructs, whereas all respondents cite the use of the usual wound care products and standard techniques for dressing and redressing wounds. Basile notes, Along with the development of seemingly thousands of products designed to augment wound healing, there really are a finite number of categories of wound care products out there, some of which bring a level of sophistication to the wound healing process. For example, I have had good success with platelet-derived growth factor gel becaplermin, which provides one of the several important growth factors involved in normal wound healing. 8 Healthcare Ledger May 2011
Basile continues, One must remember, however, that there is no single product on the market that is an end all solution for a healing wound without the application of fundamental wound care principles, namely removal of necrotic tissue through debridement, reduction of the microbial burden to the wound bed through antibiotic therapy and sterile irrigation, and adding cells or other materials to secrete or enhance levels of healing factors. Unfortunately, the drawback to using many of these advanced care products is their expense. Dunn agrees with Basile and asserts the importance of traditional medical and surgical interventions when it comes to advanced wound care products. Without applying the basic principles of surgical debridement and reduction of the bioburden in the wound bed, use of advanced products may prove ineffective. They just are not suitable in bringing about wound healing alone. Dunn also cites success in treating chronic wounds with negative pressure wound therapy, using a VAC device, which basically provides vacuum-assisted wound closure in acute and chronic wounds. Hyperbaric Oxygen Therapy Hyperbaric oxygen therapy, a treatment approved for certain nonhealing wounds, is one therapeutic option available for patients at the Berkshire facility, according to Basile. Hyperbaric oxygen therapy is a treatment in which the patient breathes 100% oxygen while enclosed in a specialized chamber at greater than normal atmospheric pressure. By superoxygenating the blood, the patient s natural wound-healing mechanisms function more efficiently. Basile adds, This form of therapy works well in patients burdened with hypoxic wounds that are refractory to other measures of treatment and is indicated for fifteen or sixteen different conditions, including select diabetic foot wounds and osteomylitis. Current Challenges and Objectives All respondents cited current challenges and objectives that if met, would enhance the delivery of adequate wound care to their communities and the population at large. All respondents noted the need for further efforts to educate hospital staff on the nature of chronic wounds and the importance of early intervention, as well as public awareness campaigns, providing general information on the development of chronic wounds in susceptible populations, such as diabetics. Dunn underscores the need for appropriate surgical consultation and if needed, intervention by a surgical specialist trained in proper wound care debridement in all patients being evaluated and treated for chronic wounds. Dunn asserts, There is a deficiency in education in many facilities offering wound care when it comes to the basic fundamentals of wound healing. There needs to be an emphasis on the value of surgical interventions when it comes to identifying the need for debridement and less emphasis on nonsurgical modalities, which may not be suitable for healing, including improper use of available devices and wound care products. According to Langlois, a key wound care educational initiative is in development at Holyoke. We will be participating in a wound care training certification program and Internet training course that will provide educational initiatives pertaining to Holyoke staff who are routinely responsible for providing wound care to patients. According to Basile, patients at longterm care facilities are in great need for delivery of wound care, especially in cases where a patient is bedridden or has other transport issues, making a trip to the wound center impractical. There is a planned effort underway at Berkshire to certify nurse practitioners in wound care so they can be used in long-term facilities to assess and treat wounds at the bedside. Basile continues, We anticipate great results from this endeavor and hope other communities will develop or have similar programs underway to provide adequate wound care to those in these types of facilities. Langlois agrees with Basile that the local community could benefit from delivery of adequate wound care, especially in patients confined to a home setting. We rely on the Holyoke Visiting Nurse Services to care for patients who are immobile and bedridden and are treated at home or in a long-term care facility. These nurses are all qualified to provide assistance to patients receiving wound care in the home setting, explains Langlois. References 1. Mustoe T. Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy. Am J Surg. May 2004; 187(5):S1:S65 S70. 2. Branski LK, Gauglitz GG, Herndon DN, et al. A review of gene and stem cell therapy in cutaneous wound healing. Burns. July 2008. 3. Moreo K. Understanding and overcoming the challenges of effective case management for patients with chronic wounds. Case Mgr. Mar Apr 2005;16(2):62 63, 67. 10 Healthcare Ledger May 2011