the Role of Patricia Turner BSN, RN, CWCN, CWS

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1 Understanding the Role of Outpatient Wound Centers Patricia Turner BSN, RN, CWCN, CWS Outpatient wound centers are somewhat of a specialty unto themselves within the world of wound care. The focus of the center, types of patients treated, and the resources involved in running a center are specific to the outpatient population. Typically, the most common types of wounds seen in an outpatient setting are lower extremity ulcers, predominantly venous leg ulcers and diabetic foot ulcers. Many of these patients are affected by a quality of life issue. They are able to maintain their condition on an outpatient basis, but their quality of life is greatly impacted by the need to care for their wound on a daily, ongoing basis. 32 Healthy Skin I

2 Venous leg ulcers are the most common type of chronic wound, affecting an estimated 1 percent of the U.S. population. Venous leg ulcers are the most common type of chronic wound, affecting an estimated 1 percent of the U.S. population. 1 Up to 85 percent of lower extremity ulcers are related to chronic venous hypertension. 2 Diabetic foot ulcers are another common type of wound seen in the outpatient setting. An estimated 8.3 percent of the U.S. population has diabetes, 3 and up to 25 percent of people with diabetes will develop a diabetic foot ulcer. 4 Understanding where these patients can go for ongoing care and treatment, and understanding the workings of an outpatient wound center, can better prepare us as clinicians and resources in the field of wound care. To better understand how we, as clinicians, can utilize a wound center as part of the continuum of care, we will follow a patient through her treatment at an outpatient wound center. Improving Quality of Care Based on CMS Guidelines 33

3 Wound centers are almost always considered an outpatient department of a hospital. Mrs. Green is a 73-year-old patient with diabetes who was recently admitted to a community hospital with an episode of hyperglycemia. Her family had been visiting her and her husband for the holidays. One evening, Mrs Green had unusual symptoms of headache, confusion, and trouble seeing which rapidly progressed. Her family called 911, and an ambulance transported Mrs. Green to the hospital s emergency department. She had very high blood glucose. Upon initial assessment, the admitting nurse noted a 2 x 1.5 cm wound on the plantar aspect of her right foot. Mrs Green s medical condition was addressed, her blood sugar was returned to normal, and she was discharged with home care to take care of her wound. The home care nurses saw Mrs. Green for several weeks, utilizing standard wound care. With little to no improvement to the wound, the home care nurse referred Mrs. Green to the hospital outpatient wound center. Wound centers are almost always considered an outpatient department of a hospital. The hospital may choose to run the wound center or sign a contract with a wound management company to run the wound center. Advantages of a wound management company include access to specialized training, clinical practice guidelines, policy and procedures, and documentation and data collection that are standard across all the centers the company manages. Whether a management company is involved or not, the patient should expect to work with specialized clinicians to develop an aggressive treatment plan, with the goal of healing in a timely fashion. A referral to a wound center may come from the patient s primary care physician, a home care nurse, or even as a referral after discharge from an acute care stay. Long-term care facilities also refer patients to outpatient wound centers for evaluation and treatment. Patients may even refer themselves! The goal is to visit to a wound center for specialized treatment from a staff that is knowledgeable in wound care. Mrs. Green s nurse made an appointment for her to visit the outpatient wound center within a few days. The secretary at the wound center gathered some information over the phone from Mrs. Green regarding her wound and her health insurance. Since Mrs. Green had Medicare, there were no referrals or pre-authorizations needed, and the secretary explained to Mrs. Green that Medicare would be billed for the services at the wound center just like any other outpatient department of the hospital, and for a consultation with the physician at the center. The secretary explained to Mrs. Green that she would need to bring any previous test results or studies and a list of all her current medications with her to the appointment. She told Mrs. Green to expect the first visit to be lengthy, since the nurse and doctor spend a lot of time with patients during the initial visit. Once the patient is scheduled for an appointment, the wound center administrative staff determines if the insurance company requires any referrals or pre-authorizations. The initial visit to a center is lengthy. The nurse and physician take a comprehensive history to make sure they understand and address all the potential factors that affect wound healing. The center staff gather information about past and current treatment for the wound and review any previous medical records or tests that may assist them with the wound s history. The physician will perform a complete physical exam. Making sure to address all co-morbidities and conditions as he helps develop the patient s treatment plan. When Mrs. Green arrives for her first appointment the receptionist gives her a health history form to fill out, and all paperwork is gathered and placed into her chart. The wound center nurse then escorts Mrs. Green to an exam room. She asks Mrs. Green a series of questions related to the onset and treatment of the wound and reviews her health history and list of 34 Healthy Skin I

4 Most wound centers utilize a multidisciplinary approach. From receptionist to nurse to physician, each team member plays a role in the development of the patient s treatment plan. medications. The nurse also takes the dressing off the wound, cleans the area, and performs a comprehensive assessment of the wound. This includes measuring the wound, photographing it and documenting all of the findings. Finally, the physician comes in to review Mrs. Green s chart with her as he begins to discuss options for the treatment of her wound. Most wound centers utilize a multidisciplinary approach. From receptionist to nurse to physician, each team member plays a role in the development of the patient s treatment plan. The wound center nurse s basic documentation of the condition of the wound includes wound location, wound measurement, tissue type, periwound skin condition, wound exudate or odor, and also photography. Generally, this information is added to a database that allows the staff to track the progress of the wound as the patient s treatment plan progresses. This statistical analysis of progress is one of the advantages of an outpatient center. The staff is able to make changes to their patient s treatment plan based on outcomes. In today s health care arena, outcomes-driven practice is a valued entity. The ability to measure outcomes also allows the wound center to be benchmarked against and compared to other existing centers, particularly when the center is run by a management company. The wound center physician discusses Mrs. Green s treatment plan with her. He explains that because she has a lower extremity wound, he will be sending her for some studies to test the circulation of her leg, even though he can palpate her dorsalis pedal pulses. He also performs a monofilament test to determine the extent of neuropathy in Mrs. Green s feet as he explains what neuropathy is and informs her about the importance of good footwear. He also lets her know that he will be making suggestions for her to see a pedorthist, someone who specializes in protective footwear, once the wound gets close to healing. The physician sharply debrides the wound, removing all non-viable tissue and taking a tissue culture. The physician then orders lab tests for Mrs. Green to test her blood sugar control. The physician and nurse discuss options for offloading the area, and make a note to incorporate that into the plan of care after the circulatory studies come back. The wound center nurse then dresses the wound, arranges for Mrs. Green s return visit to the center in two weeks and contacts the home health care agency that referred Mrs. Green to discuss the treatment plan and the wound care that will need to be done at home. Mrs. Green leaves the wound center with discharge instructions and patient education pamphlets on diabetes and foot care. The wound center physician explains that he will contact Mrs. Green s primary care physician to discuss the visit and address any follow up on her diabetes medications, if needed. The comprehensive approach to wound care in an outpatient center includes workup for circulation, Improving Quality of Care Based on CMS Guidelines 35

5 The wound center will see the patient often, to monitor the treatment plan, and to make changes according to the wound s progress. infection, nutrition, and most importantly, the treatment plan needs to address all co-morbidites that may be affecting the patient s ability to heal. The wound itself will follow an algorithm of removing non viable tissue, when appropriate, and topical wound care that will address the wound s needs in order to maintain a moist wound environment. Concurrent treatment that addresses the individual etiology of the wound is part of the comprehensive plan, such as offloading for diabetic foot ulcers, or compression therapy for venous wounds. The wound center should communicate to external team members, such as other departments that will be doing testing for the patient, other specialists who need to be involved, the patient s primary care physician, or other caregivers, such as the home health care agency. The wound center will see the patient often, to monitor the treatment plan, and to make changes according to the wound s progresses. The center will follow the patient closely until the wound heals. The clinical staff will collaborate with the patient s caregivers and primary care physicians during the course of treatment. As the patient gets closer to healing, the staff will also consider the care and education necessary for the patient to maintain the healing state. Communication back to a patient s primary care physician or caregiver is key to the maintenance of a healed wound. Mrs. Green s wound went on to heal in a timely fashion with her visits to the wound center. Thanks to the home care nurse s knowledge about wound center services, Mrs. Green had a positive experience and a positive outcome for her wound. Now that you have an understanding of how an outpatient wound center can be a destination of healing, you can begin to include it as another step in the continuum of care for patients with slow-to-heal wounds. References 1. Collins L, Seraj S. Diagnosis and treatment of venous ulcers. American Family Physician. 2010;81(8): Available at: org/afp/2010/0415/p989.html. Accessed January 10, Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ. 2004; 328(7452): Available at: articles/pmc Accessed January 10, National Diabetes Statistics, National Diabetes Information Clearinghouse website. Available at: Accessed January 10, Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg. 2006;117(7 Suppl):193S-209S; discussion 210S-211S. Available at: Accessed January 10, Healthy Skin I

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