Wound care program improves with teamwork
Wound care program improves with teamwork
Management needs multidisciplinary approach
If you think of the traditional wound management program as changing dressings that contain high-tech medications, you’re missing the boat. A strong wound care effort involves collaboration between therapists and other staff clinicians as well as frequent monitoring of patient outcomes, according to therapists with experience in wound care.
If your rehab department is considering adding a wound care program, these pointers may help:
1. Wound management takes a multidisciplinary approach. "It’s very obvious that we [therapists] don’t have all the answers," says Carrie Sussman, MS, PT, president of Torrance, CA-based Sussman Physical Therapy and Wound Care Management Services. Sussman recommends working very closely with nurses, who frequently are the referral sources for wound healing treatments by physical therapists. Both parties need to explain the treatment each is providing to the patient and the expected outcomes and should make certain they are compatible.
The Center for Advanced Wound Care in Wyomissing, PA, was created with a team concept in mind, says Pam Unger, PT, partner and clinical director for the center. Unger serves as clinical director, and a physician serves as medical director. The center also includes a wound care department and a wound management department. The latter includes diabetic educators, vascular services, and podiatrists, who serve as consultants.
2. Approach the patient when developing outcomes. Patients should be a key part of the outcomes goal-setting process, Sussman says. "It’s not always as obvious as one might think. I once saw a patient who came in with a very heavily draining wound that had a lot of pus and odor. It was keeping her confined to home. What she wanted was to be able to control the odor so that she could get out of her house and go to church on Sundays and to see her family. That was her desired outcome."
3. Distinguish between wound care and wound management to receive proper reimbursement. "Wound care, including wound cleansing, administration of topical pharmaceuticals, and dressing changes, is typically considered a nursing service," Sussman says. "To distinguish the services of the nurse from those of a physical therapist, think of the physical therapist performing wound management, which incorporates the evaluation process of the physical therapist and the selection of interventions. It may also include the administration of these interventions or instruction, along with the wound care.
"In order to be considered a [reimbursable] PT service, it must include a service that is unique and that specifically requires the skills of a physical therapist. Examples might be: selecting elec trical stimulation protocols, or sharp wound debridement accompanied by another service, such as whirlpool or pulsatile lavage with suction. Also, rehab may be a part of the wound service such as treatment of an amputee who is undergoing gait rehabilitation," she says.
4. Develop a protocol for your wound care program. For a sample pathway:
• Include wound assessment as part of the initial evaluation done by the physical therapist.
• Determine if any interventions are needed to heal a wound or prevent a future wound from developing.
• Determine the type of intervention needed.
• Communicate the information to the attending physician or other appropriate parties.
• Determine who does what tasks. For example, who changes the dressing? It isn’t always the nurse. "Therapists are qualified to put on a dressing and topical agents, if they’re doing it in the course of providing therapy," Sussman says.
At the Veterans Administration Hospital of West Los Angeles, the protocol involves team rounds of all patients who are at risk for wound problems, says Randi Woodrow, PT, physical therapy manager. If team members see a patient at risk for developing wound problems, they will add recommendations to the patient’s chart, whether it involves a dressing change or a treatment in the physical therapy gym.
At The Center for Advanced Wound Care, patients are classified into a specific category based on the type of treatment needed, following an initial 2.5-hour visit that includes an assessment by a physical therapist and a physician and patient history data provided by a registered nurse. Patients are classified as post-surgical, traumatic, or burn patients.
The center also might use basic admitting and treatment protocols that go with each category — at least as a starting point. "The physical therapist writes a plan of care [based on these protocols] with input from team members," Unger says.
"Based on the type of case, it might include ultrasound, pulse electromagnetic induction, dressing changes, total contact casting, and exercise programs from the therapist’s perspective. It also might include antibiotics or nutritional education. But the plan of care may change as things happen with the patient," she says. Once a week, the clinic has all professionals involved in the care — from surgeons to nurses to other providers — meet to review the patients’ progress.
5. Don’t forget about prevention. Spinal cord injury patients and stroke patients are among those who frequently are at risk for wound problems, Sussman says. Prevention planning could be part of an initial evaluation as well as ongoing patient assessments.
6. Remember: There is strength in numbers. The American Physical Therapy Association has a wound management special interest group that is part of its section on clinical electrophysiology. Contact the association at (703) 684-2782 or on the World Wide Web at www.apta.org.
In addition to acting as a resource, the group has gotten involved in reimbursement issues affecting wound management in rehab settings. For example, APTA filed a class action suit against the Health Care Financing Administration protesting HCFA’s refusal to cover electrical stimulation by therapists for wound management purposes. The suit led to a court ruling that required HCFA to consider reimbursement for these services on a case-by-case basis.
7. Research costs and desired outcomes when beginning a program. Potential sources include the National Pressure Ulcer Advisory Panel, which holds regular conferences and is planning a conference for Oct. 6 in New York City. Contact the organization at (314) 909-6815. Also, Sussman has co-written a book, Wound Care: A Collaborative Manual for PTs and Nurses, with Barbara Bates Jensen, RN. The book is available from Aspen Publishing Co. for $85.
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