Center takes new approach to wound care

Diabetic patients encouraged to play active role

Many diabetics, fearful of amputation and frustrated at finding fragmented care, live for years with non-healing wounds. In Willingboro, NJ, an area with a high population of diabetics, such patients can turn to the new Rancocas Hospital Wound Care Center, which opened in March.

The center, part of a nationwide network of more than 120 wound care centers operated by Curative Health Services, allows patients to get all the care they need under one roof. An interdisciplinary team of podiatrists, vascular surgeons, endocrinologists, clinical nurse specialists, and medical technicians treats diabetics and other patients with chronic wounds. For 80% of the patients Curative sees across the nation, it works within 12 to 16 weeks.

"The wound is our only agenda," says Mary Martin, RCP, program director. "When the wound is healed, we send the patient back to the primary care physician. We have an oxymoron going on here: We heal non-healing wounds."

The Wound Care Center, which expects to see about 500 patients this year, works with people who have a wound that hasn’t shown improvement in four weeks or hasn’t totally healed within eight weeks. About 40% of the patients are diabetics; the rest have wounds resulting from pressure, venous stasis, and other causes.

Chronic, non-healing wounds affect 2% of the population, Martin says. In many cases, care is lengthy, costly — treating a pressure ulcer patient, for example, can exceed $100,000 — and, if ineffective, lead to amputation and expensive rehabilitation. About 50% of non-traumatic amputations in the United States are related to diabetes, and in New Jersey alone last year, 2,000 diabetes-related amputations were performed.

At Rancocas Hospital, staff are tailoring the elements of success proven by other Wound Care Centers in Curative’s 10-year history to their specific situation with a high number of diabetics. The keys: encouraging patient compliance, using a clinical pathway, working with a multidisciplinary team, and tracking wounds with a national database of more than 75,000 patients.

Encouraging patient compliance

One of the main reasons many diabetics and other patients live with chronic wounds is they find it too difficult and confusing to visit multiple providers to continue their care. "Here, patients see the same staff, from the receptionist to the clinical nurse manager to the physician, every time they come in," Martin says. "They don’t have to go to other cities. The disease process is very tiring; it gets discouraging. We have a camaraderie among the patients, an energy, and a trust level that helps."

But while the Wound Care Center may be convenient for patients, it doesn’t go easy on them. Patients must promise at the beginning of treatment to take an active part in the process. They are required to sign a form saying they understand that they are partners in their treatment. "If a diabetic mailman comes in with a horrible foot wound, it’s never going to heal unless he gets off that foot for a while," Martin says.

A nurse case manager keeps track of each patient’s progress and reinforces the appropriate information, says Becky Scharf, RN, BSN, CDE, clinical nurse director of the Wound Care Center. Patients are offered literature, videos, classes, and support groups.

"It’s really neat to follow these people and their wounds and to develop a relationship with them," Scharf says. "They become more comfortable asking questions, so I’m doing a lot of diabetes teaching in that 15 to 20 minutes they’re here. They get a much better grasp than if they came to a class for an hour once every couple of years."

Using a clinical pathway

A clinical path guides each patient’s treatment, providing a written reminder of issues to evaluate. The plan of care looks at the following:

• history and physical;

• concomitant disease;

• wound evaluation;

• laboratory;

• scans/radiology;

• nutrition;

• vascular assessment.

At the beginning of treatment, patients are asked specific questions related to how well they are managing the diabetes, what medications they’re taking, and how their blood sugars run normally. (See related story on a new drug treatment for diabetic foot ulcers, p. 85.) Other issues addressed include underlying causes for the wound, such as pressure, injury, infection, or other disease. Possible interventions listed on the path include:

• protection/education;

• revascularization;

• infection control;

• excision/debridement;

• skin grade/flap.

Physicians in a variety of specialties, including endocrinology, podiatry, and vascular surgery are trained in the wound care center’s clinical path. They meet at four-week intervals with the patient’s case manager to assess whether the patient is making appropriate progress, Scharf says. Case presentations are made at monthly quality assurance meetings that include physicians, case managers, clinical nurse specialists, and wound technicians.

"The wound tech, for example, may know something about a patient that I don’t," Scharf explains. "Maybe the patient told her that Meals on Wheels hasn’t been coming regularly, and so the patient isn’t eating properly. That’s something we can help fix."

Being part of a network of Wound Care Centers that tracks data on more than 75,000 patients means physicians and nurses at Rancocas don’t have to reinvent the wheel every time they see a patient. "Every wound is entered into the database," Martin says. "Having a network means that if we see a wound we’ve never seen before, we can call other centers and see what they know." The Curative system has chat rooms set up on the Internet for physicians to discuss wounds and provides quarterly and annual meetings for more formal discussions.

The database alerts the Wound Care Center to repeat customers, something the center tries to avoid. "We’re really into prevention," Scharf says. "We want to save limbs. Having a wound on one foot means they are at high risk for getting one on the other foot. We are very active in stopping that from happening."

[For more information about the Rancocas Hospital Wound Care Center, contact the following sources: Mary Martin, RCP, and Becky Scharf, RN, BSN, CDE, Rancocas Hospital Wound Care Center, Willingboro, NJ. Telephone: (609) 835-5240.]