Tips on Starting a Wound Care Center Robert 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
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
Starting a Wound Care Center
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
Starting a Wound Care Center
• 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?
Starting a Wound Care Center
“Average” Vascular Surgeon Commonly Sees…
• Ischemic wounds
• Diabetic wounds
• Venous wounds
• Surgical wounds
• Pressure wounds
Starting a Wound Care Center
“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
Starting a Wound Care Center
Why Create a Wound Care Center…
• Advantages
– Patient centric
– Multidisciplinary
– Evidence-based
– Latest advances applied
– Outcome tracking
– Doctor convenient
– Fiscal accountibility
Starting a Wound Care Center
• 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
Starting a Wound Care Center
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
Starting a Wound Care Center
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
Starting a Wound Care Center
Exam/Procedure Room
Starting a Wound Care Center
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
Starting a Wound Care Center
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
Starting a Wound Care Center
Debridements
Compression and
Wound Care
Advanced Wound Care
Skin Substitutes
Apligraf
Dermagraft
Wound Vac
HBO
Other Accessories
Starting a Wound Care Center
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
Starting a Wound Care Center
• 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
Starting a Wound Care Center
Physician/Allied Health Prof.
Wound Care
Company
Hospital
Wound Center
A Model That Works…
Starting a Wound Care Center
• 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”
Starting a Wound Care Center
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
Starting a Wound Care Center
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
Starting a Wound Care Center
• 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
Starting a Wound Care Center
OHSU Wound and Hyperbaric Center
Starting a Wound Care 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!
Starting a Wound Care Center