Five Ways to Build the Ideal Wound Clinic

October 3, 2011 — Matthew Livingston R.N. C.W.S.

Five ways to build the ideal wound clinic

1. Build a large referral base

A. Become an expert in wound care and hyperbarics (do research and publish)

B. Get in front of as many doctors as possible and share what you know. Become well connected in the hospital and the hospitals system.

C. Let them know that you are an adjunct to their care and that you will be working to keep them informed of patient progress.

D. Maintain active communications with the referring physicians.

2. Recruit all types of specialists to work as wound physicians.

A. This includes Vascular, General Surgery, Trauma, Plastics. ID, Internal Med, Podiatry. etc…

B. Make sure that there are open cross referral patterns between these doctors.

C. With this in mind, recruit doctors that have an us (not me) mentality as sharing referrals can improve patient outcome and better outcomes means more referrals.

3. Provide Advanced Wound Care

A. Have physicians who can manage complex wound etiologies such as micro-occlusive and autoimmune disorders.

B. Insure that you have physicians available who can provide surgical interventions such as complex flaps.

4. Provide a process driven wound care environment

A. Benchmark wound healing outcomes by etiology, with goals for how to improve lower preforming healing outcomes.

B. Create evidence based protocols for the care of your patients.

C. Foster staff / clinician / physician  process improvement committees which drive improvements such as clinic development, patient safety, and new product review.

5. Create accurate and seamless documentation

A. Invest in a wound care related electronic medical record (EMR).

B. Insure that the EMR company has on the ground training that not only trains towards the EMR, but also how the EMR should fit into your clinic process (I recommend Well Care Strategies TPS Full Ambulatory Solution).

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Evidence Based Notes on Pressure Ulcers

September 30, 2011 — Matthew Livingston R.N. C.W.S.

NPWT

Negative Pressure Wound Therapy increases rate of closure in stage 3 and 4 pressure ulcers

(Ubbink, Westbos, Evans, Land, & Vermeulen, 2008)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 34

Support Surfaces

Individuals at risk should be placed on a pressure redistribution surface.

(RNAO, 2005; NICE, 2005)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,   Pg 18

Nutrition

Early nutritional assessment is critical to identify patients at risk for malnutrition

(Dorner, Posthauer, & Thomas, 2009)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 10

Surgical Intervention

Evaluate the need for surgical interventions with stage 3 and 4 pressure ulcers that don’t respond to conservative pressure ulcer treatments.

(Sorensen, Jorgensen, & Gottrup, 2004)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 35

Co-morbidities related to delayed healing in Pressure Ulcers

Pressure Ulcer healing is complicated by co-morbid conditions including malignancy, diabetes, CVA, heart failure, renal failure, pneumonia.

(Berlowitz & Wilking, 1989)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

Wound Conditions related to delayed healing in Pressure Ulcers

Wounds that are larger, deeper, infected, had large amount of exudate, and /or covered with slough or eschar are less likely to heal with in 3 months and likely to heal after five to six months of treatment.

(Jones et al., 2007)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

 

Benchmark for Pressure Ulcers greater than 4 square cm

The median days to healing is 73 days for large (>4cm2) ulcers

(Bergstrom et al., 2008)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.

 

Benchmark for Pressure Ulcers greater than 4 square cm

The healing rate for stage 3 pressures was 31.5% and 23.3% for stage 4 pressure ulcers in the first 3 months (12 weeks).

(Brandeis et al., 1990)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.

 

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Teaching New Wound Clinicians

May 15, 2011 — Matthew Livingston R.N. C.W.S.

Education is a key component when adding new nurses to your wound clinic. Getting these nurses up to speed fast is important for the flow of the clinic and the success of the new employee. There are four interconnecting approaches to wound management education including, literature, classroom, internet, and one to one nurse interaction.

I find that it is best not to overwhelm the new nurse in the first week, so I usually send them home with easy reading. My favorite easy reading book for new nurses and students is Wound Care Made Incredibly Visual by Springhouse publishing. This book has very simple content and provides great graphics to enforce the written content.

Before the new nurse starts working with patients I recommend a two or three day (hands on) practicum. Ask representatives from companies that you use to assist you in this process. Consider topics such as how to take photos, how to assess the patient, review charge sheets, general product review, compression bandaging, negative pressure wound therapy, orthopedics, Apligraf, Dermagraft, total contact casts, and special wound products such as Mist therapy.

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Wound Care Tool Kit: ORC Collagen

April 26, 2011 — Matthew Livingston R.N. C.W.S.

Many wound care clinicians over the years have used Promogran and Prisma (ORC Collagen) as their treatment of choice for chronic wounds.  What I first noticed with the use of ORC collagen (Prisma and Promogran) was that chronic wounds would often undergo a new wave of contraction and granulation.  It was a product that I would  pull out of my wound care tool kit for any long- standing wound.

As the years have rolled by many of the other wound care companies have jumped into the space seeking to capitalize on the chronic wound / collagen market. But is collagen the same as ORC collagen (Prisma & Promogran)? I learned first-hand that switching (from ORC collagen) to plain collagen can lead to disappointing results when different collagen products were added to our hospital formulary.  In time I realized that plain collagen wasn’t providing the wound contraction and granulation formation that I would see with the ORC Collagen (To the point that I stopped using collagen altogether).

My question is has any one else observed this difference in quality?

Disclosure: The author of this article declares that he receives no financial reward for this posting from Systagenix (the manufacturer of ORC Collagen).

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Wound Care Toolkit: Proteasemarker

April 25, 2011 — Matthew Livingston R.N. C.W.S.

Take a look at Systagenix’s new educational offering www.proteasemarker.com .  This site shows their commitment to sharing information with clinicians regarding chronic wounds (There are lots of resources at this site). Systagenix is also bringing a product to the US market at the beginning of the next year that should revolutionize how we assess our patients. Essentually, this product (after a swab of the wound) will  quickly identify out of balance chemicals that lead to chronic wound states. Needless to say this will be a huge advantage over what has pretty much been guess-work.

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