The key to success in opening a clinic: Do your homework

Know your patients and their wounds

Perhaps the most important piece of advice for establishing a successful wound clinic is disarmingly simple: Do your homework.

"Know your population, and make sure you've done a needs assessment," says Heather Orsted, RN, BSN, ET, clinical nurse specialist for Calgary Home Care, Calgary, Alberta, Canada. Her organization, which will open a wound care clinic this fall, got a boost when it received a grant from the Community Health Resources branch of the Calgary Regional Health Authority to do a one-year review of the needs of the community. The grant came with a twofold mission - determine if a wound care clinic is needed, and develop a clinical pathway for wounds.

"We developed a multidisciplinary team to look at what [services] did exist and at the needs of our population so we could see the gaps between the two," Orsted adds. "We realized we do have a significant population that could be classified as 'walking wounded' that do not require home health care and could go outside to access services."

With some 6,000 clients in its caseload, Calgary Home Care oversees the care of about 500 wounds at any one time, she says. Staff spend about 1,000 hours a day managing dressings and conducting wound assessments. Home care coordinators perform a case management role, Orsted notes, not necessarily doing the care but making sure the patient gets the best care.

"We did a survey of our population to determine if these were acute or chronic wounds. We looked at the types of wounds and at the factors that influence healing," Orsted explains. "We discovered our breakdown of acute wounds and chronic wounds, rapid-healing vs. long-healing, was about 50-50. There are a lot of surgical wounds [that need care] because patients are being discharged [from the hospital] earlier."

When team members looked at wound care services offered in the Calgary area, which has a population of about 800,000, they realized there was no site for routine visits and wound assessment, she says. The only option was home care, which Orsted points out is not always cost-effective. While home care nurses spend an hour, travel time included, to care for a patient's wound at home, they might take care of three patients in that time in a clinic setting, she notes.

With a wound clinic available, postoperative patients who have a long-healing wound but are ready to go back to work could receive care more easily, Orsted says. "Now they have to go all the way home, meet a nurse, and then go back to the office."

Assisting in the project is a 25-member multidisciplinary Skin and Wound Assessment and Treatment (SWAT) Team that does high-end home care assessments, she adds. These team members likely will be applicants for positions at the new wound clinic.

Calgary Home Care is considering the possibility of eventually having multiple sites, rather than just one central site, for the wound care clinic, as well as expanding the services to include such services as intravenous therapy. The site that is finally selected will determine the focus of the pilot clinic that will open this fall, but it will handle both routine and acute cases, Orsted says. "We're hoping to have laboratory and X-ray services - one-stop shopping for wound care."

Physician backing a crucial factor

Gaining the confidence of physicians and having ready access to support services were keys to success for two Kaiser Permanente wound care specialists who started a clinic 10 years ago in Bellflower, CA.

When Mary Pelfrey, RN, ET, and Evonne Fowler, MN, RN, CETN, began their push for a wound care clinic, Pelfrey says, they knew what they wanted: a nurse-run clinic with easy access where patients could refer themselves and where representatives from all the appropriate disciplines could see the patient the first time he or she came in.

"If they were diabetic, we'd have a diabetic case manager see them and do all the teaching, and if they needed an appointment to get their eyes checked, we'd get them in right away," she explains.

Their goal was to decrease amputations by focusing on wound prevention, Pelfrey says. That would be done by teaching diabetics good foot care, how to recognize the signs that a wound is developing, and when to see a physician. Although the clinic treats all kinds of wounds, including ostomies, two-thirds of its cases involve diabetics, she notes.

In their efforts to establish a clinic, the two wound care specialists "got in through the back door," setting up shop in the hospital's plastic surgery wing, and the operation snowballed from there, Pelfrey says. On a typical day, the clinic may treat 20-plus patients, and the nurses also do rounds in the hospital, she adds.

"If you get [physicians'] confidence, it's all downhill from there," she says. "What we used to do is go up on the floors, see inpatients there, and put down [on the physician's order] what we thought would be the best treatment. We'd write the orders and they'd sign them. Once the doctors caught on, they seemed to like it. They'd send the patient to us for assessment, and we would do whatever treatment was necessary."

Pelfrey and Fowler devised their own wound documentation record, a detailed, comprehensive account of the treatment provided, referrals made, and medication ordered. (See form, p. 115.)

The clinic's location - part of the orthopedic clinic on the hospital's first floor and in close proximity to the triage and advice center, the emergency department, and a surgical urgent care department - is crucial to its effectiveness, Pelfrey says. A diabetic foot clinic also is part of the orthopedics area, and the hospital's vascular department is upstairs. Wound care is under the orthopedics umbrella, she explains, because of the numerous wounds related to such procedures as total knee replacements and coronary artery bypasses.

"We can call the diabetic case manager and say, 'This lady has a vascular problem - can you get her in?' If [a patient's] blood sugars are up, we make sure she gets an appointment with the diabetic clinic, and if she needs to see a doctor right away, we call and say, 'This patient needs to be seen ASAP.' Two weeks down the road [when a regular appointment is scheduled] may be too late," she adds.

If a patient calls and says he has a "hot foot" that he thinks is infected, he has immediate access, Pelfrey says. Clinic hours are 8:30 a.m. to 4:30 p.m. weekdays, but with the triage and advice center, emergency department, and surgical walk-in available, there is always a treatment alternative, Pelfrey points out.

"Being centrally located really helps," she adds. "We never know what's coming in the door." When it comes to the physical layout of a wound clinic, treatment rooms should be big enough to accommodate large patients and those who may need to go in and out on stretchers, Harris suggests, and each room should be well-stocked with supplies.

With the complicated payer mix and escalating costs facing health care providers today, a successful wound clinic must have on its staff someone who is well-schooled in reimbursement, says Ann Harris, MSN, RN, CS, an independent advanced practice nurse based in Spring Lake, MI, who has specialized in wounds for the past 10 years.

Clinicians must look beyond categories

Also at the top of her list, says Harris, is "an excellent clinician who really knows how to identify the different types of wounds and is able to look at the underlying causes and address them."

For both good patient care and optimal reimbursement, she notes, the clinician should be up to date on, for example, the latest ways of offloading the diabetic foot and debriding when it indicated. "You need someone who recognizes when [the wound] doesn't fall into certain categories and they need to look at other reasons that it's not healing."

Although most vascular wounds of the lower extremities are venous in origin, she points out there are many cases of "combination" wounds. There are several ways to treat a venous wound depending on the individual needs of the patient, Harris adds. You always have to elevate the leg and provide compression. But down the line, a plastic surgeon might look at a wound and recommend a skin graft, while another practitioner might advise letting the wound fill in, she says. The skin graft is less desirable if, say, the patient is terrified of going to hospitals. On the other hand, she points out, if the wound is very large, a skin graft might be the only reasonable choice.

Documentation of the length, width, and depth of each wound is crucial, Harris notes.

Photographs are a good way to illustrate healing progress for patients and clinicians. At the West Michigan Wound Center in Grand Rapids, where Harris works, practitioners take 35mm photographs and videos to aid in documentation, she says.