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, LLC

TM

an HMP Communications Holdings Company

Today’s

®

Contemporary Approaches to Wound Clinic Management

2013

Best Practices

8 Steps to Developing Your 'Community' Wound Team Improving Communication in the Wound Clinic Documentation Compliance Also in This Issue: Effective Recruitment Measures Business Briefs Facility in Focus April 2013 www.todayswoundclinic.com

SAWC FALL

®

THE SYMPOSIUM ON ADVANCED WOUND CARE

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Today’s

®

Volume 7, Number 3, April 2013 • www.todayswoundclinic.com

Table of Contents • Feature Articles 22

8

Effective Measurers for Recruiting Wound Clinic Staff

8 Steps to Developing a Community-Based Wound Care Team: A Practical Guide for Reaching Beyond Wound Center Walls

Finding new clinicians to provide best practices in wound care is a real challenge. This article will help both longstanding and new wound centers determine the recruitment needs for their respective organizations.

Measuring a wound clinic’s success goes beyond patient outcomes and includes the perceptions of referring clinicians. This article provides suggestions that should prove beneficial in achieving these efforts.

Chris Morrison, MD

Desmond Bell, DPM, CWS

28

12

Optimizing Wound Care Processes and Workflows to Drive Documentation Compliance

Improving Communication in the Wound Clinic

To support clinical, operational, and financial best practices, documentation must accurately reflect the work performed. Developing a workflow for documentation is an essential prerequisite to evaluate clinical efficiency and cost-effectiveness.

Because of the interdisciplinary nature of wound care, communication is critical to maintaining the process of healing. Does your wound center follow these suggested strategies? Michael Cioroiu, MD, FACS, CWS & Jeffrey M. Levine, MD, AGSF

Cathy Thomas Hess, BSN, RN, CWOCN

17

30

Making the Case for Specialized Wound Care

Diabetes Screening in the Wound Clinic: Reader Survey Results

Treatment of acute and chronic wounds is traced through a long and eventful clinical history.This article demonstrates the need for and the value of taking a specialized, interdisciplinary approach to outpatient wound care as it exists today.

Check out the results of our anonymous reader survey on the protocol for diabetes screening and follow up that occurs in US wound clinics. Our findings may surprise you.

D. Scott Covington, MD, FACS, CHWS TODAY’S WOUND CLINIC® (ISSN 1938-6311), is published by HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. TODAY’S WOUND CLINIC® website, www.todayswoundclinic.com, is registered with all major Internet search engines. Full content is available online to TODAY’S WOUND CLINIC print subscribers. Subscriptions: TODAY’S WOUND CLINIC® annual rates for US subscriptions: $99.00 annual; single copies, $39.00. Single or replacement copies of TODAY’S WOUND CLINIC® are subject to availability. To subscribe to TODAY’S WOUND CLINIC®, call (800) 237-7285, ext. 221, write to TODAY’S WOUND CLINIC®, Circulation Department, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, or visit us online at www.todayswoundclinic.com. Reprints: Bulk professional-quality reprints (minimum quantity 100) of articles may be purchased. Contact the Managing Editor at (610) 560-0500 for information.

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Advertising queries should be addressed to Jeremy Bowden, Publisher, Today’s Wound Clinic®, HMP Communi­cations, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-4154 Fax: (610) 560-0501. Email: jbowden@hmpcommunications.com Display and classified advertisinG: HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, Phone: (800) 237-7285 or (610) 560-0500 x259 Corporate Offices HMP Communications, LLC 83 General Warren Boulevard Suite 100 Malvern, PA 19355 Phone: (610) 560-0500 or (800) 237-7285 Fax: (610) 560-0502

, LLC

an HMP Communications Holdings Company

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Editorial Staff

Today’s

Clinical Editors and Founding Board Caroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS

®

Founding Editorial Board Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS

Volume 7, Number 3, April 2013 • www.todayswoundclinic.com

Managing Editor Joe Darrah jdarrah@hmpcommunications.com

Table of Contents

Web Editor Samantha Alleman salleman@hmpcommunications.com

Departments

Business Staff Executive Vice President Peter Norris pnorris@hmpcommunications.com

4 From the Editor Dot Weir, RN, CWON, CWS 6

34

VP/Group publisher Jeremy Bowden jbowden@hmpcommunications.com Publisher Kristen J. Membrino kmembrino@hmpcommunications.com

Business Briefs Physicians and NPPs: Maintain Medicare Referring, Ordering, & Supervising Capabilities Kathleen D. Schaum, MS 

HMP Communications, LLC

NPWT: Powered & Non-Powered

PRESIDENT BIll Norton Controller Meredith Cymbor-Jones Vice President, Special Projects Jeff Hall Marketing Manager Stephanie Manzo

44 Industry Insider 48

Classified Sales Associate Jenn Ratcliffe jratcliffe@hmpcommunications.com

Clinician’s Report

36 Facility in Focus Main Line Health

Sales Associate Brian Hill bhill@hmpcommunications.com

Creative Director Vic Geanopulos vgeanopulos@hmpcommunications.com

An Inside Look at ACell Inc.

Art Director Bernadette Zeminski bzeminski@hmpcommunications.com

Advertiser’s Index

Senior Production Manager Andrea Steiger asteiger@hmpcommunications.com

TWC Online

Find us on Facebook @ www.facebook.com/todayswoundclinic

www.todayswoundclinic.com

Follow us on Twitter: @TWCjournal

www.twcjournal.wordpress.com

Production/ Circulation Director Kathy Murphy kmurphy@hmpcommunications.com Audience Development Manager Bill Malriat

Reader Picks:

MEETING PLANNER Cynthia Noonan

Top online visits from March 1-31 1) Identifying New ICD-10-CM “Buzzwords” in Diabetes Terminology 2) Raising the Debate on Wound Care and Diabetes Education 3) The Debridement Dilemma Returns

MEETING PLANNER Trisha Keppler

HMP Communications Holdings, LLC Chief Executive Officer Jeff Hennessy Chief Financial Officer Dan Rice

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 an HMP Communications Holdings Company Editorial Correspondence should be addressed to Managing Editor, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-0500 /Fax: (610) 560-0502. Editorial policy: TODAY’S WOUND CLINIC® seeks to provide practical, timely insight into clinical and operational issues inherent to the success of an outpatient wound center. Program Directors, Medical Directors, and Clinical Managers (including Nurse Practitioners and other professional wound care providers across multiple disciplines) will benefit from the interactive nature of feature articles and regular departments that address medical and practice management options and perspectives affecting fiscal and, most importantly, patient outcomes of wound clinics. Articles from knowledgeable, experienced practitioners are invited and will be subject to Editorial Board review. , LLC

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Senior Vice President Anthony Mancini Director of e-Media and Technology Tim Shaw Senior Director of Marketing Corey Krejcik Sr. Manager, IT Ken Roberts

4/4/13 6:33 PM


Editorial Staff

Today’s

Clinical Editors and Founding Board Caroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS

®

Founding Editorial Board Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS

Volume 7, Number 3, April 2013 • www.todayswoundclinic.com

Managing Editor Joe Darrah jdarrah@hmpcommunications.com

Table of Contents

Web Editor Samantha Alleman salleman@hmpcommunications.com

Departments

Business Staff Executive Vice President Peter Norris pnorris@hmpcommunications.com

4 From the Editor Dot Weir, RN, CWON, CWS 6

34

VP/Group publisher Jeremy Bowden jbowden@hmpcommunications.com Publisher Kristen J. Membrino kmembrino@hmpcommunications.com

Business Briefs Physicians and NPPs: Maintain Medicare Referring, Ordering, & Supervising Capabilities Kathleen D. Schaum, MS 

Classified Sales Associate Jenn Ratcliffe jratcliffe@hmpcommunications.com

Clinician’s Report

HMP Communications, LLC

NPWT: Powered & Non-Powered

PRESIDENT BIll Norton Controller Meredith Cymbor-Jones

37 Facility in Focus Main Line Health

Vice President, Special Projects Jeff Hall Marketing Manager Stephanie Manzo

44 Industry Insider

Sales Associate Brian Hill bhill@hmpcommunications.com

Creative Director Vic Geanopulos vgeanopulos@hmpcommunications.com

An Inside Look at ACell Inc.

Art Director Bernadette Zeminski bzeminski@hmpcommunications.com

48 Advertiser’s Index

Senior Production Manager Andrea Steiger asteiger@hmpcommunications.com

TWC Online

Find us on Facebook @ www.facebook.com/todayswoundclinic

www.todayswoundclinic.com

Follow us on Twitter: @TWCjournal

www.twcjournal.wordpress.com

Production/ Circulation Director Kathy Murphy kmurphy@hmpcommunications.com Audience Development Manager Bill Malriat

Reader Picks:

MEETING PLANNER Cynthia Noonan

Top online visits from March 1-31 1) Identifying New ICD-10-CM “Buzzwords” in Diabetes Terminology 2) Raising the Debate on Wound Care and Diabetes Education 3) The Debridement Dilemma Returns

MEETING PLANNER Trisha Keppler

HMP Communications Holdings, LLC Chief Executive Officer Jeff Hennessy Chief Financial Officer Dan Rice

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 an HMP Communications Holdings Company Editorial Correspondence should be addressed to Managing Editor, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-0500 /Fax: (610) 560-0502. Editorial policy: TODAY’S WOUND CLINIC® seeks to provide practical, timely insight into clinical and operational issues inherent to the success of an outpatient wound center. Program Directors, Medical Directors, and Clinical Managers (including Nurse Practitioners and other professional wound care providers across multiple disciplines) will benefit from the interactive nature of feature articles and regular departments that address medical and practice management options and perspectives affecting fiscal and, most importantly, patient outcomes of wound clinics. Articles from knowledgeable, experienced practitioners are invited and will be subject to Editorial Board review. , LLC

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Senior Vice President Anthony Mancini Director of e-Media and Technology Tim Shaw Senior Director of Marketing Corey Krejcik Sr. Manager, IT Ken Roberts

4/5/13 12:24 PM


fromtheeditor

I

t seems impossible to believe that within a month’s time we will once again be heading to the Symposium on Advanced Wound Care (SAWC)/Wound Healing Society (WHS) conference in beautiful Denver, CO. SAWC/WHS will bring together more than 2,000 individuals who are dedicated to the Dot Weir art and science of taking care of patients living with acute and Co-Editor of TWC chronic wounds. A high percentage of these attendees practice their art and science in an outpatient wound care center. Hence, the interest and awareness of Today’s Wound Clinic always gets a boost during the symposium. Once again, our articles are so very fitting to the delivery of outpatient care, focusing on current issues that we all are or will be facing. As healthcare changes, so must we, and we must keep up with those changes. From the clinician’s perspective, it’s often easy to keep abreast of changes in guidelines, new products, and therapies as long as we make it our business to do so. We cannot accept that simply receiving one-time training can allow us to practice at a high level without further education. In this issue, Chris Morrison, MD, discusses recruitment of personnel, citing points to consider as we look at delivery of services in this environment and the importance of excellent screening and expectation-setting among those we hire. This applies to both the clinical and provider staff. But the requirement of continuing education, perhaps the expectation that staff should be working toward certification, can assure the potential of getting “in a rut” will be mitigated. As we move toward the day when we are all truly paid for performance, the critical importance of cutting-edge care and awareness of things like prognostic indicators will take on the importance they should.

Ensure Efficiency Wound care clinic managers and directors have a never-ending need to make sure all of their “ducks are in a row” with coordination of providers, documentation, coding, billing, and review of denials to assure their centers are legally and financially in compliance. As always, Kathleen Schaum, MS, provides yet another critical reminder of our responsibilities to ensure that our providers have current and properly executed enrollment with Medicare so that we are ordering, referring, and supervising for appropriate reimbursement and that all regulatory requirements are met. Further, Cathy Thomas Hess, BSN, RN, CWOCN, provides an outstanding overview of documentation requirements, outlining each section of the medical record and how each should build and paint a picture of the patient that will lead the clinical team to making the best possible decision relative to the comprehensive care of the patient from diagnostics to treatment. It makes such good sense … if we don’t build all clinical information as a platform for our care, critical issues will be missed. As we look at quality issues that have been covered in previous issues, it’s only the documentation that can aid us in monitoring whether those quality measures have been met.With all this considered, Des Bell, DPM, CWS, shares a compelling piece discussing how wound centers can make their mark in their communities beyond the work of pens, pads, and billboards through utilization of social media, volunteerism, and public involvement. Dr. Bell epitomizes this with his dedication to Save a Leg, Save a Life.

Visit Us AT SAWC The details outlined in this issue reflect the information needs of TWC readers. As always, we welcome your comments, suggestions, and ideas that will make TWC a continued critical resource in your wound center. If you are at SAWC, please visit the HMP Communications booth, our staff, and editorial board. n

Today’s

®

Editorial Board Founding Editorial Board Members Co-Editor of Today’s Wound Clinic Caroline Fife, MD, FAAFP, CWS Co-Editor of Today’s Wound Clinic Dot Weir, RN, CWON, CWS Christopher A. Morrison, MD, FACHM, FCCWS Valerie Sullivan, PT, MS, CWS Kathleen D. Schaum, MS

Editorial Board Members Andrew J. Applewhite, MD, CWS, UHM Leah Amir, MS, MHA Desmond Bell, DPM, CWS Trisha Carlson, MSN, MBA-HCM, RN, CWCN Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA Moira Hayes, MHA, RRT, CHT Cathy Thomas Hess, BSN, RN, CWOCN Harriet Jones, MD, BSN, FAPWCA Robert S. Kirsner, MD, PhD Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA Pamela Scarborough, PT, DPT, MS, CDE, CWS Susie Seaman, NP, MSN, CWOCN Tere Sigler, PT, CWS, CLT-LANA Pamela G. Unger, PT, CWS, FCCWS Randall Wolcott, MD, CWS

, LLC

an HMP Communications Holdings Company

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 © 2013, HMP Communications, LLC. All rights reserved. Reproduction in whole or in part prohibited. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of HMP Communications, LLC, the editorial staff, or any member of the editorial advisory board. HMP Communications, LLC is not responsible for accuracy of dosages given in articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement or approval of the products or services advertised or of their effectiveness, quality or safety. HMP Communications, LLC disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Content may not be reproduced in any form without written permission. Reprints of articles are available. Contact HMP Communications, LLC for information.HMP Communications, LLC (HMP) is the authoritative source for comprehensive information and education serving healthcare professionals. HMP’s products include peer-reviewed and non-peer-reviewed medical journals, national trade shows and conferences, online programs and customized clinical programs. HMP is wholly owned subsidiary of HMP Communications Holdings LLC. Discover more about HMP’s products and services at www.hmpcommunications.com.

Dot Weir, RN, CWON, CWS

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April 2013 Today’s Wound Clinic®

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businessbriefs

Physicians and NPPs: Maintain Medicare

Referring, Ordering, & Supervising Capabilities

Kathleen D. Schaum, MS Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

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well-known adage claims “the most expensive medical implement is the physician’s pen.” In actuality, if physicians and non-physician practitioners (NPPs) do not write a referral and/or an order, medical care cannot be provided to Medicare beneficiaries. Only physicians and certain types of NPPs are eligible to order or refer items or services for Medicare beneficiaries. Those qualified healthcare professionals who typically order or refer for chronic wound care services are: • physicians (doctor of medicine or osteopathy, doctor of podiatric medicine) • physician assistants • clinical nurse specialists • nurse practitioners • interns, residents, and fellows.

Ordering and Referring History As of Jan. 1, 1992, physicians or suppliers who bill Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if the service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was selected as the National Provider Identifier (NPI). Beginning in October 2009, the Centers for Medicare & Medicaid Services (CMS) began to alert providers who submitted Medicare claims that the identification of the ordering/referring provider was missing, incomplete, 6

or invalid, or that the ordering/referring provider was not eligible to order or refer. The alerts on the claims were different for various providers. The informational messages that Part B providers and suppliers found on their adjusted claims were: N264 Missing/incomplete/invalid ordering provider name. N265 Missing/incomplete/invalid ordering provider primary identifier. The informational message that durable medical equipment (DME) suppliers found on their adjusted claims was: N544 Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected, this will not be paid in the future. The informational message that Part A home health agencies found on their adjusted claims was: N272 Missing/incomplete/invalid other payer attending provider identifier. In December 2009, CMS added NPIs to more than 200,000 Provider Enrollment, Chain, and Ownership System (PECOS) enrollment records of physicians and NPPs who were eligible to order and refer, but who had not updated their PECOS enrollment records with their NPIs. On Jan. 28, 2010, CMS made “ordering referring reports” available to the public that contain the NPIs and the names of physicians and NPPs who have current enrollment records in PECOS and who are of a type/specialty that is eligible to order and refer. Providers can now verify if a physician/NPP who orders an item or service or who submits a

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referral has a PECOS enrollment record (www.cms.gov/Medicare/ProviderEnrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html). Enrolled physicians/NPPs are listed in alphabetical order by last name. The ordering referring report is replaced each week to ensure accuracy. NOTE: Providers could receive an order or a referral from a physician or an NPP who just completed his/her Medicare enrollment and who is not listed in the current week’s report. Check the following week’s report to verify if he/she is listed. Section 6405 (Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals) of the March 2010 Affordable Care Act requires physicians or other eligible professionals who order or refer items or services for Medicare beneficiaries to have a Medicare enrollment record. They can accomplish this very important task by using the PECOS online or by completing the paper enrollment application (CMS -8550). NOTE: Those physicians or NPPs who don’t have a current Medicare enrollment record should enroll now.

May 1: Ordering and Referring Edits To help protect Medicare beneficiaries and the integrity of the Medicare program, effective May 1, CMS will activate ordering/referring claim edits.These edits will determine whether or not the ordering/referring provider: 1. Has a current Medicare enrollment record that contains a valid NPI [name and NPI must match] and 2. Is of a provider type that is eligible to order or refer for Medicare beneficiaries. These edits will deny Part B, DME supplier, and Part A home health agency www.todayswoundclinic.com

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businessbriefs claims as non-covered services. When Part B providers’ and suppliers’ claims are denied due to the ordering/referring edits, the following denial messages will be on the claims: 254D Referring/Ordering Provider Not Allowed to Refer. 255D Referring/Ordering Provider Mismatch. 289D Referring/Ordering Provider NPI Required. When Part A home health agency claims are denied due to ordering/referring edits, the agency will receive one of two possible edits: 37236 or 37237. The message on both edits will be the same: Covered charges or provider reimbursement is greater than zero, but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS, but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code.

Wound Care Ordering/ Referring Tactics Wound care physicians/NPPs who order/refer items or services should ensure: 1. They have a current Medicare enrollment record by: a.Checking the ordering/referring report to be sure they are on the report and that it contains their NPI. b. Contacting their designated Medicare enrollment contractor and asking if he/she has an enrollment record in Medicare and it if contains their NPI. c. Using the online PECOS to look for their Medicare enrollment record. 2. They submit an application for Medicare enrollment if they are not currently enrolled. 3. They submitted an opt-out affidavit to a Medicare contractor within their specific jurisdiction, if they are physicians who have opted out of Medicare but wish to order items or services for Medicare beneficiaries. 4. They are a type/specialty that can order

or refer items of service for Medicare beneficiaries. Wound care physicians, hospital-based outpatient wound care departments (HOPD), DME suppliers, and Part A home health agencies that bill Medicare for items and services that were ordered or referred should ensure: 1. The physicians and NPPs from whom they accept orders and referrals have current Medicare enrollment records and are of the type/specialty eligible to order or refer in the Medicare program. 2. They are correctly spelling the ordering/referring provider’s name. 3. Their claims are properly completed: a. Do not use“nicknames”on the claim. b. Do not enter a credential or title (eg, “Dr.”) in a name field. c. On paper CMS 1500 claims,in item 17, enter the ordering/referring provider’s first name first, and last name second. d. Do not enter the name and NPI of an organization, such as a group practice that employs the physician or NPP. Ensure the name and NPI belong to the specific physician or NPP who ordered/referred. e. Make sure the qualifier in the electronic claim is a person,not an organization.

Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service Hospital outpatient therapeutic services and supplies must be furnished under the order of a physician or other practitioner practicing within the extent of the Social Security Act, the Code of Federal Regulations, and state law. They must be furnished by hospital personnel under the appropriate supervision of a physician or an NPP. This does not mean that each occasion of service by an NPP must also be the occasion of the actual rendition of a personal professional service by the physician responsible for care of the patient. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient’s progress and, when necessary, to change the treatment regimen. A hospital

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service or supply would not be considered incident to a physician’s service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment. CMS requires direct supervision by an appropriate physician or NPP in the provision of all therapeutic services to hospital outpatients and critical-access hospital (CAH) outpatients. CMS expects that hospitals already have the credentialing procedures, bylaws, and other policies in place to ensure that hospital outpatient services furnished to Medicare beneficiaries are being provided only by qualified practitioners in accordance with all applicable laws and regulations. Direct supervision means the physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure.The physician or NPP does not have to be present in the room when the procedure is performed or within any other physical boundary as long as he or she is immediately available. Immediate availability requires the immediate physical presence of the supervisory physician or NPP.The supervisory physician or NPP cannot be performing another procedure or service that he or she could not interrupt, may not be so physically distant from the location where the therapeutic services are being furnished that he or she could not intervene right away, etc. The hospital or supervisory practitioner must judge the supervisory practitioner’s relative location to ensure that he or she is immediately available. The supervisory physician or NPP must have, within his or her state’s scope of practice and hospital-granted privileges, knowledge, skills, ability, and privileges to perform the service or procedure. The supervisory responsibility is more than the capacity to respond to an emergency. It includes the ability to take over performance of a procedure or provide additional orders. CMS would not expect that the supervisory physician or NPP would make all decisions unilaterally without informing or consulting the patient’s treating physician or NPP. contiuned on page 48

Today’s Wound Clinic®

April 2013

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8 Steps

to Developing

a Community-Based Wound Care Team: A Practical Guide for Reaching Beyond Wound Center Walls

Measuring a wound clinic’s success goes beyond patient outcomes and includes the perceptions of referring clinicians. Ensure that your facility is making its mark in your community. Desmond Bell, DPM, CWS

D

espite the obvious cliché, time truly is of the essence when it comes to wound care — regardless of etiology. Since the advent of “wound care centers” in the 1990s, the concept of receiving interdisciplinary treatment under one roof by a group of specialists has grown exponentially and is dominated by several companies that develop such centers, which are typically hospital-based. That being said, outside companies do not manage every hospital-based wound center that exists today, and not all wound care providers are affiliated with wound centers. Despite the prevalence and acceptance of these centers, many patients never receive early referrals or are taught why early intervention versus self-management is so important. Countless dollars are spent on advertising and marketing of wound centers, yet, in many instances, there exists a disconnect that impedes the timely care they’re supposed to provide. At the same time, potential referring physicians may have negative perceptions of wound centers related to quality of care, billing practices, and overall reputation that can all contribute to reluctance on their part (and among patients alike) to entrust such services. This places a heavy responsibility on those clinicians who are seeking to develop an interdisciplinary wound care team within their local community to do so in a comprehensive, responsible manner that ensures the basis of a solid reputation that extends beyond the reach of the wound center into the

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community at large.This article provides suggestions that should prove beneficial in achieving these efforts.

1) Do Your Research

As with any endeavor, one’s “homework” requires self-education. Further readings should be conducted, but here are a couple examples related to wound care: Peter Sheehan, MD, et al published a landmark paper in 2003 that still rings true today.1 The paper highlights the importance of time as it relates to the healing of diabetic foot ulcers (DFUs). During their trial, Sheehan and his colleagues noted a change in the percentage of wound area as a prognostic value in helping distinguish those who will have a difficult time in healing versus those who will heal readily, when utilizing fundamental standard wound care. In April 2010, the Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients With Diabetes were established by Robert Snyder, DPM; Jason Hanft, DPM; Lawrence Lavery, DPM; and several other noted experts in the wound care field as a comprehensive guide to assist providers in an evidence-based approach to treating DFUs. Among the panel’s messages among, which further validate Sheehan’s findings, is the premise that prolonged healing times increase the risk for morbidity, infection, hospitalization, and amputation, so expeditious wound closure should be the primary goal in the treatment of DFUs.2

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2) Consistency Counts

Many providers who are staffed in a wound center may only be in the facility on a part-time basis, meaning there are no guarantees that everyone will be “on the same page” unless a true effort is made by the clinical coordinator, hospital, or management company as well as all staff employed. We also know the majority of patients seen in wound centers are living with multiple comorbidities typically necessitating management by several specialists. The dynamics of a wound center can be unique and challenging, as not all providers utilize the most current technologies or evidence–based methods we have available, especially among those who are in the twilight of their career and may be reluctant to embrace new methods. But it’s well documented that the team approach to wound care is not only the most effective way to practice, but the most efficient. Functioning as a team also spreads and shares potential liability and can easily be accomplished by regularly scheduling interdisciplinary team meetings and fostering an environment where suggestions and constructive criticism are sought after and accepted. All team members should be trained to use any programs utilized and all protocols put in place within one facility. The team approach has especially been validated in the management of diabetes.3-5

3) Social Media: Here to Stay & Should be Utilized

You are not alone if you remain over-

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bestpractices whelmed or intimidated by the presence and pressures of social media. The use of smart phones and mobile computers by both young and old has paralleled the explosion of this resource. If you’re in a wound center or are seeking to launch one, you need a professional social media presence if you’re going to maximize your opportunities to communicate with patients and fellow providers as well as to research other providers in your region. However, do not try to master social media overnight. Instead, browse the various sites as you would TV channels or web sites in general. As you no doubt have learned to surf in both capacities, you can begin to adapt your use of social media with the same mindset. Consider these advantages even if you have been slow to adapt to the use of social media: • It’s a very cost-effective (free) way to spread the word. Social media is exactly that — news and information-sharing that’s maintained socially. You can build credibility within your community as well as the wound care community at large by using these sites. An easy way to start is to post photos of your wound center or announce news of a grand opening and/or new staff. • You control what you share. As your social media site’s “administrator,” you dictate what you communicate. Sharing patient success stories (while being mindful of HIPAA compliance) and posting articles that have been published in other venues (while being mindful of copyright laws) are great ways to reinforce your brand. Making regular posts and updates daily or weekly will help you increase your number of online “followers,” “members,” and “fans.” Repetition is the key to success.

4) Use Your EHR to Full Capacity

While we’re on the subject of informatics, an electronic health record (EHR) that focuses on wound care not only ensures documentation compliance and, most likely, appropriate billing levels, it can demonstrate your level of expertise to other providers and

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establish further incentive for them to refer to your center. Include photos and notes if you have a case of a patient that a provider has made to you (again, be mindful of HIPAA and HITECH).

5) Network, Network, Network

Show other providers your work by constructing marketing materials that detail your practice and, when feasible, hand deliver such records to referring providers. Use this opportunity to also develop relationships with other referring practices. Additionally, networking opportunities abound through dinner programs that function as a means to present scientific information regarding wound care. These events offer great ways to gain insight while meeting fellow providers. Industry representatives know who the dedicated providers are in a given region and can serve as a conduit to bring the wound care team together. Industry plays an important role in wound care on multiple levels. Product development and marketing are the lifeblood of any company, but the importance of education is also recognized as a way to increase sales and raise awareness within the medical community.

6) Volunteer

The giving of your time as a local volunteer is not only satisfying, it shows a level of sincerity. Participating in healthcare screenings is a great way to meet other like-minded providers and to further enhance your reputation. Consider a neighborhood church, for example.

7) Refer to other providers

As difficult as it may be to imagine, there are patients who will find their way into your wound center who are not under the care of a primary physician. Referrals to primary care providers can play an important role among wound care specialists.Vascular interventionalists, infectious disease specialists, and others who show an interest in wound care may not realize their roles within a community wound care team, as they are typically focusing on their tasks at hand. Making referrals allows these groups to recog-

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nize you as someone who is engaged in wound care beyond wet-to-dry dressings.

8) Join or Create a Professional Organization

As the co-founder and board member of the Save A Leg, Save A Life (SALSAL) Foundation, I’d be remiss to not encourage others to join the organization, a multidisciplinary nonprofit dedicated to the reduction in lower extremity amputations and improving wound healing outcomes through evidencebased methodology and community outreach. One of the purposes of SALSAL is to bring providers together in a collegial forum that facilitates better care and outcomes. Even podiatrists and vascular surgeons who never interacted previously now collaborate in treating patients, regardless of whether they work in the same wound center. The team approach expedited by SALSAL is open to anyone interested. Learn more by visiting www.savealegsavealife.org. n Desmond Bell is a board-certified wound specialist (CWS-American Academy of Wound Management, for which he’s a board member) and a fellow of the American College of Certified Wound Specialists. He is founder of the Limb Salvage Institute and Wound Care on Wheels LLC. A frequent lecturer and author on wound care, peripheral arterial disease, and diabetes, Bell was awarded the Frist Humanitarian Award by Specialty Hospital in 2009. He may be reached at drbell@ savealegsavealife.org. References 1. S heehan P, Jones P, Caselli A, Giurini JM,Veves A. Percent change in wound area of diabetic foot ulcers over a four-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003; 26(6):1879-1882. 2. S nyder RJ, Kirsner RS, Warriner RA, Lavery LA, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Wounds. 2010; 56(Suppl 4):S1-S24. 3. D  river VR, Fabbi M, Gibbons, G, Lavery LA. The costs of diabetic foot: the economic case for the limb salvage team. J of Vasc Surg. 2010; 52(3), Supplement:17S–22S. 4. F  rykberg RK. Team approach toward lower extremity amputation prevention in diabetes. JAPMA. 1997;87(7):305-312. 5. S umpio BE, Aruny J, Blume PA. The multidisciplinary approach to limb salvage. Acta Chir Belg. 2004;(104):647-653.

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Optimizing Wound Care Processes and Workflows to

Drive Documentation Compliance To support clinical, operational, and financial best practices, documentation must accurately reflect the work performed.

Cathy Thomas Hess, BSN, RN, CWOCN

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hen thinking about the goals of documentation, consider the following: • Any word has a singular meaning. • Words placed in a particular order and sequence along with punctuation create a sentence. • Sentences denote thoughts. • In healthcare, our thoughts and actions performed for patients are documented to justify the work achieved.

Legal Medical Record Drivers

One of the most critical functions of the medical record’s multiple purposes is to plan and provide continuity of care for a patient’s medical treatment. The documentation in the medical record does provide for this function, but in many instances healthcare providers forget that the additional function of the medical record includes: • Providing information for the financial reimbursement to hospitals, healthcare providers, skilled-nursing facilities, and patients; • Providing legal documentation in cases of injury or other legal proceedings; • Providing information for quality assurance and peer-review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and • Providing the critical information in an accreditation process such as the Joint Commission, Centers for Medicare & Medicaid Services (CMS), Undersea and Hyperbaric Medical Society, etc. As the medical community moves forward to become compliant with federal laws, the most common documentation tool used to collect the patient information is an electronic medical record (EMR), the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and

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staff from a single organization who are involved in the individual’s health and care.1 The clinician must remember that data collected in the medical record serves as the instrument for demonstrating the clinician’s ability to plan, coordinate, and evaluate patient care. Therefore, developing a workflow for documentation is an essential prerequisite for a facility to evaluate the clinical efficiency and cost-effectiveness of its staff. Proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation. Once established, the documentation system should become the framework of clinical practice for all members of the wound care team.

Process and Workflow Drivers

Clinical decision making for skin and wound management is dependent upon the types of patients we manage in our care settings, the skillsets of the clinicians making the decisions for those patients, the products we have available within our facilities to improve skin and wound care, and documentation platform to capture our work. Essentially, the chain of events that should occur to move the skin and wound care forward is through defined process management and workflow (Figure 1). “Process” is defined by Merriam Webster as “a series of actions or operations conducing to an end.” And, with every process, are defined, targeted goals. All actions taken in skin and wound management need to be clearly defined through skin- and wound-caring processes. Workflow includes the structure or work system features and processes that support care.2 Designing clinical and operational workflow requires review and customization of current clinical and documentation practices for an efficient

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outcome. Current practices include the operational processes for registration, coding, and billing as well as the cognitive workflow by clinicians. Producing the right mix of operational oversight and clinical experience grounded with a solid documentation system will produce efficient business practices and optimal patient flow and care.

Revenue Management & Medical Necessity

Revenue cycle processes that include patient registration, compliant billing, and denial management compliment the documentation process for a fiscally successful department.These processes are governed by policy and Medicare is required by the Social Security Act to ensure payment is made only for those medical services that are reasonable and necessary. Policies specify the circumstances under which Medicare covers specific services. Further, most payers have implemented medical necessity guidelines for wound care services. CMS has defined medical necessity as: “No Medicare payment shall be made for items or services that are not reasonable and/or necessary for the diagnosis or treatment of illness or injury to improve the function of the malformed body member.” In short, the clinical documentation, diagnosis, and Current Procedural Terminology (CPT-4)3 codes reported must meet medical necessity or the claim will not be paid. Medical necessity guidelines can be payer specific, but most often payers follow those guidelines published by CMS’ national coverage determinations or Local Coverage Determinations (LCDs). It is also prudent to be familiar with the managed care payer agreements and limitations. From the time patients are called to schedule services, the documentation process begins. Patient demographic and payer information is gathered and medical necessity and coverage are con-

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bestpractices firmed and entered into the documentation system. Let’s consider the following components of the revenue cycle that drive the wound care department’s fiscal strength: Revenue Cycle Component Checklist4 A) Schedule Initial and Follow-up Visits B) Reason for visit: 1. R  eview physician order for complete diagnosis information 2. What is the primary reason for the visit? 3. Do comorbidities exist? C) Patient Demographics: 1. Verify first and last name spelling. 2. C  onfirm patient address. 3. C  onfirm patient telephone number. D) Patient Insurance Information: 1. R  equest complete information: primary, secondary and/or tertiary. 2. B  e careful to identify the insured. Do not make assumptions that the main insured is the patient. 3. Is this a Medicare secondary payer? 4. Is this a Managed Care Payer? a. I s the wound care department contracted? b. Will the service be paid at a non-par rate? c. Does the payer authorize wound care in the plan? — Is your wound care department an authorized payer center? d. Will the patient be sanctioned penalties for using the wound care center? E) Verify the Coverage Prior to Patient’s Visit: 1. D  etermine coverage for the diagnosis(es) on the physician order. 2. I mplement the Medicare Advance Beneficiary Notice if medical necessity or coverage fails. 3. D  etermine if the payer has coverage limitations. 4. I dentify if utilization parameters will be a concern. 5. O  btain Precertification and/ or Preauthorization numbers. F) Front-end Collections 1. P  repare the patient for co-pay, co-insurance, or deductible based on the findings prior to the visit.

Figure 1

Optimize Processes and Workflows

-Patient Demographics -Payer Information -Payer Authorization -Payer Compliance -Payer Utilization -Medical Necessity -Advanced Beneficiary Notice (ABN) -Coding -Billing -Audit -Compliance -Authentication -Query Management -Denial Management

$ $

$

-Documentation Standards -Medical Necessity -ICD9/10 -Procedure codes -HITECH Rules -Quality Indicators -Quality Metrics

Drive Documentation Compliance © 2013 Cathy Thomas Hess. Used with permission.

2. P  lan collecting the patient obligation at the point of service.

Charge & Billing Drivers

The wound care department’s charge description master represents chargeable services and will include CPT-4 and Healthcare Common Procedure Coding System (HCPCS) Level II codes5 that define the services conducted and/or used during the visit. Insurance payers expect clean, compliant claims. CPT-4, HCPCS Level II with modifiers will describe the procedures and skin substitutes used and ICD-9 represents diagnosis codes. All services and supporting diagnosis(es) need to be reported timely and completely. Review the billing software edits to manage National Correct Coding Initiative, Medically Unlikely Edits, and payer specific billing compliance.

Medical Necessity & Denial Management Drivers

As indicated in the initial step of the revenue cycle management process, payer medical necessity verification should be completed prior to the service.There will be times when it is “thought” that the service would be considered medi-

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$

-Compliant EMR -Clinical & Operational Workflows -Best Practice Pathways -Outcome data -Benchmarking Reports -Care Coordination

cally necessary based on the inquiry confirmation, but a denial may result. Every effort must be made to insure complete and compliant documentation. It is the medical documentation that will be used to dispute and potentially overturn the denial.

Documentation Drivers

Documentation components comprising the medical record provide the platform for medical necessity and continuity of care. Skin and wound care documentation can combine a variety of information-gathering tools reflecting the wound’s status across the healing continuum. Remember, the goal of documentation is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis. Diligent documentation determines dollars.When assessing the patient with a skin or wound condition, the details of the documentation should reflect the following data points as appropriate: Chief Complaint The chief complaint is the first step toward complete documentation for the skin and wound care patient. The chief complaint bridges the reason for

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bestpractices assessment and screening tools, and skin and wound assessments. The HPI This checklist is provided as the first step in the review audit process to identify obvi- should include a complete chronologious discrepancies and prompt a more intense compliance review. cal account of the presenting problem to date. The majority of this information is Facility Review Audit Checklist subjective based on interviewing the paq Has your facility developed a requirement crosswalk between the evaluation/man- tient. If there is more than one chronic agement (E/M) level and the ambulatory patient classification (APC)? condition discussed (ie, lower leg pain, q Does the medical record documentation support the requirements from the facilityheadaches), make sure to document this developed crosswalk? in the HPI. This will assist in justifying q Does the departmental staff understand the requirements for medical record the needed orders. documentation to support the facility-developed crosswalk?

Figure 2: Medical Necessity Review Audit Checklist6

qHas the department staff received the appropriate education and training in the utilization of the crosswalk? q Are the appropriate modifiers being utilized in the department? q Has the departmental staff been trained in the use of modifiers? q Does the medical record documentation support the utilization of a modifier? q Does the wound care department have a tool that provides the facility billing entity with a listing of services rendered? q Is there appropriate communication between the departmental staff and the billing entity of the facility (ie, coding/billing updates, revisions to facility crosswalk, etc.)? q Does the facility billing entity audit the wound care department’s documentation in order to support the APC billed? Professional Review Audit Checklist q Is there an appropriate tool to correspond the services rendered to the professional billing entity? ☑ q Does the professional billing entity audit the medical record documentation to assure the appropriate E/M level has been billed? q Does the professional billing entity provide the practicing professional with necessary updates to determine service codes? q When modifiers are appended, is there supporting medical record documentation? q Does the practicing professional provide supporting medical record documentation to correspond with the level of E/M billed for his/her professional service? q If templates are utilized, does the practicing professional document utilizing the guidelines for the template? q Does the documentation require the date and the signature of the practicing professional providing the service? q Has the practicing professional identified the appropriate diagnosis code for the services rendered? q Has the practicing professional identified the appropriate diagnosis coding for ancillary services ordered? q Does the medical record documentation for the wound assessment and description support the dressing ordered (following appropriate Medicare Part B surgical dressing policy for specific region)? q Are procedures appropriately documented in the medical record to support the service code identified and billed? q Are the services being rendered by the professional appropriate for the wound care department setting? © 2013 Cathy Thomas Hess. Used with permission.

the patient’s visit to the detailed history and physical captured by the practitioner, capturing the medical necessity for the visit. The clinician should document the specific reason the patient is visiting the practitioner. This statement should be clearly written, describing

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the reason for the patient’s visit, in the patient’s own words. History of Present Illness (HPI) An HPI provides necessary subjective information for the practitioner to review in conjunction with a review of symptoms, physical examination, risk

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Past Medical, Family, and Social History There are many chronic illnesses or diseases, medications, allergies, diets, or activities of daily living that can lead to poor wound healing. A review of the patient’s past medical, family, and social history should be captured. This thorough documentation will provide complete information needed for the clinician to link any and all disorders to the patient with the chronic wound. Review of Systems Defined by CPT-4 as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced,” a symptom review is a general discussion related to the patient’s complaints or problems identified during the visit that provides necessary subjective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; physical assessment; and wound/skin/ostomy assessment. Physical Examination A focused examination pertinent to the skin condition, ostomy, or wound healing history, the physical examination is based on the patient’s history and the nature of the presenting problems and provides necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; and wound/ ostomy/skin assessment. Documentation of the affected system(s) is mandatory in this section.

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bestpractices Risk Assessment Risk assessments are used as predictors to ensure systematic evaluation of individual risk factors and exist for areas of the skin at risk, such as pressure ulcers and diabetic foot ulcers. Nutritional risk-assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutritional risk. Manual risk-assessment tools are part of the prevention of many disease states. Other factors (ie, laboratory values, radiologic studies, vascular studies) should be taken into consideration when evaluating a patient at risk. Risk assessment provides necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; physical examination; and wound/ostomy/ skin assessment. Manual Screening Tools Manual screening tools are objective findings that assist the clinician in determining an accurate diagnosis. Screening results provide necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; physical examination; and wound/ostomy/skin assessment. Wound/Skin Assessment Wound care documentation can combine a variety of information reflecting the wound’s status across the healing continuum. Providing an accurate description of the wound’s characteristics is critical during each patient visit. These objective findings assist the clinician in mapping the care during the wound-management process. The values obtained include etiology, qualitative information, and quantitative information. Establishing the etiology or cause of the wound or skin condition will help identify the correct classification and management process. Underlying medical conditions such as poor nutrition, diabetes, and/or neuropathy may explain why the wound is healing slowly. These underlying conditions need

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to be treated concurrently. Finally, treatment history is significant because the clinician may learn which management modalities have been tried and have been either successful or failures. Qualitative information should capture the anatomical location; classification of tissue-layer destruction; edema; or swelling of tissues, wound exudate, odor, pain, periwound skin description, type of tissue exposed, wound bed description and wound color, and wound margin condition. Quantitative information may include ankle and calf circumference, photograph of the wound, surface area of wound, wound depth, and undermining.

activities.Validating the impact of the education by measuring retention of the material is paramount for a successful plan.

Procedures Performed Components of the procedure performed include, but are not limited to, consent for the procedure, physical examination completed and updated in the last seven days, time-out parameters, name of physician and/or clinician performing the procedure, pre-operative diagnosis, procedure description, anesthesia used, noted complications, post-operative diagnosis, and the procedure performed (eg, techniques and tissues removed). Review LCDs as they relate to the specific procedure performed. There are important details to document within your procedure note to make you fully compliant with your documentation.

There are many important reasons for auditing documentation, including assessment of medical record completeness, determining the accuracy of documentation to ensure medical necessity, and discovering lost revenues (Figure 2).6 Proactive monitoring and auditing are essential to test and confirm compliance with legal requirements. The auditing function is the check and balance for your documentation.When auditing a medical record, documentation is examined to determine if it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, compliance with the organization’s policies and procedures, and compliance with payer regulations may not be identified. Keeping one’s finger on the pulse of clinical and regulatory changes for documentation requirements can be a daunting task. However, this is one task that everyone needs to stay abreast of for the benefit of wound care business and patients. n

Ordering Supplies and Tests The physician/non-physician provider (NPP) must supply an order for all of the care the patient receives related to the treatment. In many cases, it is important that the physician/NPP document the reason for the order to justify one’s actions. Patient Education Patient education and compliance are the cornerstones to successful wound and skin care. The educational needs of the patient should be evaluated on an individual basis beginning with the nonjudgmental assessment of the patient’s current knowledge base relevant to the plan of care determined. An educated clinician should direct the educational

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Plan of Care/Discharge Instructions Designing, developing, and executing a clinical plan of care that is straightforward and comprehensive is paramount. Discharge summaries should be provided to patients in writing. The summaries can include diagnosis, summary of tests or procedures performed, medications prescribed during the visit, potential side effects of any tests or medications, and follow-up instructions.

Audit and Compliance Drivers

Cathy Thomas Hess is vice president and chief clinical officer at Net Health, Pittsburgh, PA. She may be reached at chess@nhsinc.com. Gail A Burke, CPAM, partner with the Manchester Group, Hoboken, NJ, contributed to this article. References for this article can be found online at www.todayswoundclinic.com

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Making the Case

for Specialized Wound Care Despite vast improvements in wound care, nonhealing chronic wounds remain a challenge to all providers. A comprehensive approach by specialists remains ideal. D. Scott Covington, MD, FACS, CHWS

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lthough many physicians routinely treat acute wounds in their day-to-day practice, the variety and complexity of nonhealing chronic wounds presents a particular challenge. As with any chronic disease process, a wound, regardless of its cause, frequently requires intervention by multiple healthcare disciplines to address the many conditions and comorbidities that impact wound healing. This article demonstrates the need for and the value of taking a specialized, interdisciplinary approach to outpatient wound care.

What’s the Problem?

By definition, a wound becomes ‘chronic’ when it fails to proceed through an orderly and timely process to produce a sustained anatomic and functional result.1 Chronic wounds are typically due to a number of wellunderstood etiologies: unrelieved pressure, venous reflux, arterial insufficiency, infection, and a variety of cancer-related and inflammatory conditions.2 Of particular challenge are wounds occurring in the 26 million Americans living with diabetes mellitus. The literature suggests that ap-

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proximately 15-25% of these individuals eventually develop foot ulcers.3 Moreover, the recurrence rate after initial healing is significant: More than 50% of ulcers return within two years and up to 24% of these patients ultimately undergo amputation. A study commissioned by the American Diabetes Association (ADA) in 2012 revealed diabetes has reached the status of “public health crisis,” costing the US at least $245 billion in 2012, a 41% increase over the last analysis done in 2008. This figure includes $176 billion in healthcare costs and an estimated

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bestpractices $69 billion in indirect costs, such as lost productivity and disability.4

A History Lesson on Wound Care

The treatment of acute and chronic wounds as an area of medical specialization is traced through a long and eventful clinical history with origins in ancient Egypt and Greece. Details of the use of lint, animal grease, and honey as topical treatments for wounds are found in literature circa 1500 BC. The Greeks were the first to differentiate between acute and chronic wounds, calling them “fresh” and “nonhealing,” respectively.5 Greek surgeons serving Roman gladiators made many contributions to the world of wound care. Notably, they acknowledged the importance of maintaining wound-site moisture to ensure successful closure.6 The 19th century witnessed the introduction of several profound medical advances impacting the practice of modern wound care. These include the development of sterile surgical technique, Louis Pasteur’s theories of the impact of microbes on disease, and Joseph Lister’s use of carbolic acid (phenol) as a microbiologic agent in surgery and gauze. The next major advances came in the mid-20th century with the rediscovery of the importance of moist wound-site care preparations and the use of polymer synthetics for wound dressings.

Wound Care Today

New approaches to wound treatment continue to become more sophisticated and capture the attention of both wound care clinicians and research scientists. Areas of novel research are focusing upon recombinant DNA technology and genetic engineering to amplify the healing process. Additionally, a variety of new products and procedures including semi-synthetic human skin, dermal scaffolds, hyperbaric oxygen therapy (HBOT), negative pressure wound therapy (NPWT), topical growth factors, and a multibillion dollar dressing industry that lends strength to the growing armamentarium of tools

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valued in the challenging effort to heal chronic wounds. Despite evolving technological advances, wound healing has been challenged with consistent and accurate methods of care delivery. This has been manifest by a lack of standardized treatment and interdisciplinary collaboration as well as insufficient evaluation of clinical outcomes to drive meaningful care. The majority of chronic wounds are still managed by clinicians with varying degrees of expertise in their private office. Despite this, studies suggest patient outcomes are better when care is provided in an environment of focused expertise.7 Moreover; as the medical needs and expenditures for chronic wound care have increased markedly over the past decade, wound care centers have grown in number nationwide. The viability of these centers, like all outpatient services, depends largely on their ability to deliver a differentially superior care experience as well as meet the evolving reimbursement’s demands for cost effectiveness. It’s estimated that 1,600 outpatient wound care centers are actively treating patients today.8 Interestingly, more than half of these are managed by outsourcing companies, with a progressive increase in this trend seen over recent years. Reasons for this include the ability of such companies to effectively navigate the myriad of challenges associated in running a specialty clinic while simultaneously giving attention to the practical considerations of operational efficiency and expense management. Management companies offer initial and ongoing quality improvement, exemplary compliance standards, ongoing benchmarking capabilities, and extensive clinical and operational training opportunities to further develop wound care staff. A theme common to advanced practice wound care centers today is the necessity for a complete assessment of both the wound and the patient. Typically, this begins with a thorough initial assessment in an effort to determine the wound’s etiology and classification, the overall health status of that patient and

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his/her ability to comply with needed therapies. Because 60% of diabetic foot ulcers (DFUs) have an ischemic component, vascular diagnostic testing frequently results in vascular surgical or endovascular interventions. Radiologic imaging is usually required to identify the presence of osteomyelitis, and medical and surgical subspecialty consultations are often required. Based on this evaluation, a treatment plan is designed to optimize the therapies best suited to address the patient’s needs. As outlined below, a comprehensive treatment plan typically involves numerous steps in the sequence appropriate to complete wound closure.

Comprehensive Treatment: A Sample Approach

Assessment of Blood Flow: This is the first step in the healing process, arguably the most important, and should precede the use of other advanced treatments in an attempt to maximize their subsequent effectiveness. It is well known that wounds without blood flow will not heal. Conversely, the likelihood of successful healing is predictably associated with the ability to accurately access and correct vascular perfusion abnormalities. Debridement to Prepare Wound Bed: Debridement involves removal of all non-viable tissue present in the wound, as well as stimulation of growth factors that contribute to healing. Ideally, this procedure is associated with minimal tissue loss while lending to the preservation of functional anatomy. As noted above, debridement should sequentially follow tissue revascularization. As such, the surgeon’s experience in this area, accompanied by appropriate vascular surgery support, is important to achieve optimal results.9 Providing Infection Control and Treatment: A foot ulcer serves as a portal of entry for bacteria that can lead to wound infection. Appropriate diagnosis and treatment of infections is critical, as mild cellulitis can rapidly progress to a limb-threatening infection if left untreated.10 Selection of Dressings: Effective

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bestpractices use of dressings is essential for optimal wound management. The concept of a clean, moist wound-healing environment is widely accepted and paramount to timely wound closure. Wound dressings that promote such decrease the risk of infection, as well as minimize tissue dehydration and cell death. Moreover, accurate dressing selection frequently translates into a cost savings to both patients and providers by minimizing treatment-related complications and the frequency with which dressings must be changed. Pressure Offloading: Ulcerations often occur in high-pressure areas of the insensitive foot, and successful healing and prevention involves the use of total contact casting, half shoes, short leg walkers, and felted foam dressings to relieve the pressure on the foot. Regardless of the offloading technique employed, patients with DFUs must reduce their daily activity until the ulcer has completely healed. Optimizing Tissue Growth: Even when basic, high-quality care principles are followed, some chronic wounds fail to respond to appropriate treatment. In these instances, advanced healing modalities such as NPWT, HBOT and skin substitutes are often employed to transition wounds from a chronic to active healing process. NPWT: The use of NPWT devices may be useful in treatment of nonhealing wounds to reduce edema, remove bacterial products, and enhance wound contracture to promote ultimate closure. Significant clinical experience and published research has demonstrated the effectiveness of this technology, particularly in post-surgical wound healing and in the management of open surgical wounds, amputation sites, and pressure ulcers. HBOT: HBOT works by increasing the concentration of oxygen supplied to the healing wound. By simple diffusion physics, it also increases the distance that oxygen molecules can travel from blood vessels into healing tissues. Clinical benefits associated with HBOT typically include vasoconstriction (reduction of

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edema) while maintaining tissue oxygenation, increasing collagen synthesis, angiogenesis, and enhancing leukocyte function (fighting infection). A wealth of data exists to support the use of systemic HBOT for wound healing.This includes five meta-analyses and 13 controlled trials, seven of which were randomized in construct. As a result, in 1999 the ADA released a consensus statement on the diabetic foot, stating that HBOT was beneficial as an adjunctive therapy in certain diabetic ischemic wounds. Additionally, the cost effectiveness of adjunctive HBOT as a treatment modality is increasingly apparent. A study by Guo et al modeled a cohort of 1,000 patients with severe DFUs (Wagner classification three or above). The costeffectiveness model estimated the incremental cost per additional quality-adjusted life year gained at years one, five and 12 was $27,310; $5,166; and $2,255, respectively if HBOT had been used in addition to routine care.This study concluded that HBOT in the treatment of DFUs is cost effective, particularly on a long-term basis.11 Skin Substitutes and Biologic Therapy: A new category of advanced wound products has been developed in response to an improved understanding of the impaired wound healing that’s integral in the chronic wound. Pathophysiologic defects such as decreased growth factors, production, and cellular inactivity have led to the development of products that address these deficiencies. Products in this category include recombinant platelet-derived growth factor and biological skin substitutes.

Future Directions

Given the declining health of our aging and ever-expanding patient population, the need for specialized wound care is vitally important. This mandates a comprehensive evaluation and consistent application of the best evidence available in the care of our wounded patients. It also means creating new evidence through an ongoing analysis of the healing process to understand and

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correct wound pathophysiology at a molecular level. Additionally, it should be the goal of all wound care practitioners to apply the most clinically and cost-effective therapies, given the looming financial concerns facing our healthcare economy. When we unite as a community of professionals in a combined effort to advance the field of wound care beyond its current status as a fledgling medical specialty, all will benefit. n D. Scott Covington is chief medical officer at Healogics, Jacksonville, FL. References 1. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994;130(4):489-493. 2. Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA. HMP Communications: 2001. 3. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med. 1996;13(suppl 1) S6-S11. 4. Economic costs of diabetes in the US in 2012. Diabetes Care. Published ahead of print March 6, 2013, doi:10.2337/dc12-2625. 5. Ovington, LG. The evolution of wound management: ancient origins and advances of the past 20 years. Home Healthcare Nurse. 2002;20:652-656. Association for the Advancement of Wound Care, statement on comprehensive multidisciplinary wound care, 2005. 6. Sipos P, Gyory H, Hagymasi K, Ondrejka P, Blazovics A. Special wound healing methods used in ancient Egypt and the mythological background. World Journal of Surgery. 2004;28: 211-216. 7. Margolis DJ, Kantor J, Berlin JA: Healing of diabetic neuropathic foot ulcers receiving standard treatment: A meta-analysis. Diabetes Care. 1999;22:692–695. 8. Healogics market research statistics on US wound care centers, 2013. 9. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Wound Rep Reg. 2002;10:354-359. 10. Veves A, Giurini J, LoGerfo F. The diabetic foot: Medical and surgical management. Humana Press, Totowa, NJ. 2006. 11. Guo S, Counte MA, Gillespie KN, Schmitz H. Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers. Int J Technol Assess Health. 2003;19(4):731-737.

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Effective Measurers

for Recruiting Wound Clinic Staff Finding new clinicians to provide best practices in wound care is a real challenge. How should this be conducted? Chris Morrison, MD

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n this evolving era of outcomes-based, cost-effective medicine, wound care programs are challenged to meet a new standard of improved healing rates and diminished liability – all at a lower cost. Gratefully, the science of wound care has evolved into an unofficial medical specialty that is devoted to implementing best practices so that programs can meet financial challenges. However, one real hurdle remains: implementing best wound care practices across the healthcare continuum in order to create a new standard for the treatment of chronic wounds. The industry has seen tremendous growth in hospital-based outpatient wound clinics as hospitals recognize the importance of adding wound care and hyperbaric medicine as both a service and a business line. This expansion, along with the expertise of management and consultant services that have driven clinical and financial success in these outpatient programs, can be credited with helping to develop a new standard of care.With many years of experience, along with more data and research to refer to, we as providers have a better understanding of how to treat chronic wounds in a cost-effective manner. Still, outpatient wound clinics currently treat only a small subset of pa-

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tients who can benefit from these new best practices, and the industry needs to further expand its knowledge and clinical expertise for patients — many of whom face limitations in their ability to get specialty care due to their own financial challenges or being homebound or housed in a skilled-nursing facility. Many times, when skilled-care facilities and home health agencies need to ensure best practices are being met, they turn to the expertise of recruitment, staffing, and consultation agencies that can provide clinicians who can maintain the appropriate standard of care needed and expected in today’s complicated wound care industry. Through education, certification, and training, these companies can produce needed staff members (on a permanent and /or temporary basis) who can work in any setting across the continuum. But in order to staff one’s wound care center appropriately and effectively, an honest, comprehensive assessment must be made internally so that the proper clinician(s) can be recruited.This article will help both longstanding and new wound centers determine the recruitment needs for their respective organizations and how to follow up on addressing those needs adequately.

April 2013 Today’s Wound Clinic®

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A Need for Recruitment

As wound care has developed into a subspecialty service (both clinically and operationally) and physicians as well as allied clinical experts have devoted their careers to this field, we must find innovative ways to create and implement wound care experts into underserved settings. An article published by David G. Armstrong, DPM, MD, PhD, et al examined five-year mortality rates for neuropathic and ischemic diabetic foot ulcers, amputations, and various other conditions (including more prevalent types of cancer).1 (See Figure 1.) Mortality rates for prostate and breast cancers were found to be 8% and 18%, respectively, showing a sharp decline in previously much higher rates for these conditions. This is likely a result of applying research knowledge, data, and clinical expertise across the entire healthcare industry to create a standard of care for best practices. When standards of care are in place, all patients, regardless of setting, can be offered protocol that’s based on a best-practice model and that’s implemented to promote optimal outcomes. However, it was also found that 45-55% of all patients diagnosed with a neuropathic or ischemic ulcer, or with a diabetes-related amputation, will die within five years.1 (See www.todayswoundclinic.com

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bestpractices

Dermagraft

97

100

86

80

Percent

Figure 1.) For those clinicians working in a best-practice environment, these statistics may seem extremely inflated, if not appalling. We must remember that most patients with these conditions do not have the resources to come to a bestpractice environment, and the clinicians, facilities, and agencies caring for these patients have not had the training and education to implement what we know as standards of wound healing. This has left a gaping hole in wound outcomes across the continuum of care. Without appropriate education to the programs and the physicians caring for patients outside of a dedicated wound center, we will continue to see a discrepancy in care and the presence of “reactive wound care” as opposed to cost-effective, proactive prevention and more appropriate healing clinical guidelines. Organizations like recruitment agencies can assist hospitals and wound centers in acquiring well-educated, experienced staff members to promote best practices. However, when seeking staffing resources it’s incumbent upon the hiring party to focus its search on the most rel-

55

60 45

40 20

18

48

18

8

0

evant staff to recruit. Depending on the size of a wound program, recruited staff may just be responsible for daily wound care practice for each (smaller programs) or more administrative roles such as staff management and delegation. There are several steps that can be taken in order to determine proper staffing for the wound center. Here are a few of the most critical: 1.  Devise a “skills list.” Some pro-

®

Human Fibroblast-Derived Dermal Substitute Essential Prescribing Information Numbers in parentheses ( ) refer to sections in the Directions for Use of the product labeling. Device Description: Dermagraft is a cryopreserved human fibroblast-derived dermal substitute. (1) Intended Use/Indications: Dermagraft is indicated for use in the treatment of full-thickness diabetic foot ulcers greater than six weeks duration which extend through the dermis, but without tendon, muscle, joint capsule, or bone exposure. Dermagraft should be used in conjunction with standard wound care regimens and in patients that have adequate blood supply to the involved foot. (2) Contraindications: • Dermagraft is contraindicated for use in ulcers that have signs of clinical infection or in ulcers with sinus tracts. • Dermagraft is contraindicated in patients with known hypersensitivity to bovine products, as it may contain trace amounts of bovine proteins from the manufacturing medium and storage solution. (3) Warnings: None (4) Precautions: Caution: The product must remain frozen at -75°C ± 10°C continuously until ready for use. Caution: Do not use any topical agents, cytotoxic cleansing solutions, or medications (e.g., lotions, ointments, creams, or gels) on an ulcer being treated with Dermagraft as such preparations may cause reduced viability of Dermagraft. Caution: Do not reuse, refreeze, or sterilize the product or its container. Caution: Do not use the product if there is evidence of container damage or if the date and time stamped on the shipping box has expired. Caution: Dermagraft is packaged with a saline-based cryoprotectant that contains 10% DMSO (Dimethylsulfoxide) and bovine serum. Skin and eye contact with this packaging solution should be avoided. Caution: Dermagraft has not been studied in patients receiving greater than 8 device applications. Caution: Dermagraft has not been studied in patients with wounds that extend into the tendon, muscle, joint capsule, or bone. Dermagraft has not been studied in children under the age of 18 years, in pregnant women, in patients with ulcers over a Charcot deformity of the mid-foot, or in patients receiving corticosteroids or immunosuppressive or cytotoxic agents. Caution: To ensure the delivery of metabolically active, living cells to the patient’s wound, do not hold Dermagraft at room temperature for more than 30 minutes. After 30 minutes, the product should be discarded and a new piece thawed and prepared consistent with Preparation for Use instructions. Caution: The persistence of Dermagraft in the wound and the safety of this device in diabetic foot ulcer patients beyond six months has not been evaluated. Testing has not revealed a tumorigenic potential for cells contained in the device. However, the long-term response to these cells is unknown. Caution: Always thaw and rinse product according to the Preparation for Use instructions to ensure the delivery of metabolically active, living cells to the patient’s wound. Caution: Do not use Dermagraft after the expiration date indicated on the labeled unit carton. (5) Adverse Events: In clinical studies conducted to date, the overall incidence of reported adverse events was approximately the same for patients who received Dermagraft compared to those who received the Control treatment. (6) Maintaining Device Effectiveness: Dermagraft must be stored continuously at -75°C ± 10°C. Dermagraft must be thawed and rinsed according to the Preparation for Use instructions. After the initial

22_26_TWC_April_recruitment.indd 23

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grams choose to have an all-nursing staff. While this is an admirable goal, is it completely necessary and cost-effective? Consider which duties could be managed safely and efficiently by a licensed practical nurse or a medical assistant. Registered nurses are needed for nursing assessment, diagnosis, and case management; but how much of their time is spent on non-essential paperwork, phone calls, or tasks such

application of Dermagraft, subsequent sharp debridement of the ulcer should continue as necessary. Additional wound preparation should minimize disruption or removal of previously implanted Dermagraft. (13) Patient Counseling Information: After implantation of Dermagraft, patients should be instructed not to disturb the ulcer site for approximately 72 hours (three days). After this time period, the patient, or caregiver, should perform the first dressing change. The frequency of additional dressing changes should be determined by the treating physician. Patients should be given detailed instructions on proper wound care so they can manage dressing changes between visits. Compliance with off weight-bearing instructions should be emphasized. Patients should be advised that they are expected to return for follow-up treatments on a routine basis, until the ulcer heals or until they are discharged from treatment. Patients should be instructed to contact their physician, if at any time they experience pain or discomfort at the ulcer site or if they notice redness, swelling, or discharge around/from the ulcer. (8) How Supplied: Dermagraft is supplied frozen in a clear bag containing one piece of approximately 2 in x 3 in (5 cm x 7.5 cm) for a single-use application. The clear bag is enclosed in a foil pouch and labeled unit carton. Caution: Dermagraft is limited to single-use application. Do not reuse, refreeze, or sterilize the product or its container. Dermagraft is manufactured using sterile components and is grown under aseptic conditions. Prior to release for use, each lot of Dermagraft must pass USP Sterility (14-day), endotoxin, and mycoplasma tests. In addition, each lot meets release specifications for collagen content, DNA, and cell viability. Dermagraft is packaged with a saline-based cryoprotectant. This solution is supplemented with 10% DMSO (Dimethylsulfoxide) and bovine serum to facilitate long-term frozen storage of the product. Refer to the step-wise thawing and rinsing procedures to ensure delivery of a metabolically active product to the wound bed. (9) Customer Assistance: For product orders, technical support, product questions, reimbursement information, or to report any adverse reactions or complications, please call the following number which is operative 24 hours a day: Shire Regenerative Medicine Customer Service (877) DERMAGRAFT or (877) 337-6247 Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician (or properly licensed practitioner). Shire Regenerative Medicine, Inc. US PAT Nos. 4,963,489; 5,266,480; 5,443,950 ©2012 Shire Regenerative Medicine, Inc. All Rights Reserved DERMAGRAFT is a registered trademark of Shire Regenerative Medicine, Inc.

11095 Torreyana Road San Diego, CA 92121-1104

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bestpractices Encouraging Leadership to Facilitate Hospital-Based Wound Care The most important component to strengthen and/or develop a facility-based wound program is by empowering staff members to assume leadership roles, preferably at all management levels. These roles should be expected of those individuals who will take the initiative to develop clinical guidelines and protocol, documentation requirements, billing and regulatory processes to ensure maximized reimbursement, ongoing education for facility staff, data measurement and reporting, and, possibly most importantly, establishing external resources through networking and community involvement so that available resources can be accessed when questions or challenges arise. When facilities cannot afford a clinical/operational expert to fulfill this roll, it may be best to seek a management or recruitment group that can provide this expertise for wound care programs.

as cleaning and preparing patient rooms and administrative medical record management? Make a list of the skills that coverage is specifically needed for, and let that guide your recruitment needs. 2.  Develop job descriptions. Once the essential duties and skill sets are known, these needs can be addressed by devising job descriptions that can be used for determining performance evaluations and making the interview/review process for candidates that much easier. 3. Determine compensation. Existing pay scales and compensation policies may already be in place, but if any changes to a position have been made these items should be reviewed. Remuneration must provide adequate incentive and be comparable and equitable with similar positions. 4. Conduct all methods of recruitment. Consider seeking candidates through Internet searches, print advertising, job fairs, and word of mouth. As we have learned more about the science of wound care and the need for an individualized and aggressive diagnostic and treatment approach to ensure best outcomes, wound care has become a physician-driven specialty. The need for physician-driven services lies at the core of the advanced practice standards for debridement, biologic dressing, hyperbaric oxygen therapy, and customized medicine such as genetic testing and compounding. Therefore, the ideal 26

wound program will be led by a physician who’s committed to continued education, comfortable with overseeing a staff and implementing best practice programs, and ensuring appropriate practice is followed. (The development of a multidisciplinary team approach can be implemented to utilize all available resources at hand.)

Evaluating Potential

When utilizing the services of a recruitment agency, hiring the best staff member becomes a crucial task and test of a wound center’s manager. Making the best hire affects a facility’s overall costs, turnover, staff relations, overall morale, and, patient satisfaction and outcomes. When the “wrong” person is hired, other staff may become resistant, morale may drop, patient care may be compromised, turnover and training costs rise, and life for the manager can become complicated. Finding good staff members is not based on whims or when “the right person comes along.” Although the hiring process can be tedious, time consuming, and even expensive at times, there is no doubt that the effort spent will be extremely beneficial. No matter how good people think they are at judging the character of others, there is a lot that goes into making a successful hire. These steps should be used: 1. Candidate screening: Review resumes and select candidates who best match the qualifications stated in the job description, and perhaps

April 2013 Today’s Wound Clinic®

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conduct telephone pre-screening interviews. Select the top candidates and send those resumes to the hiring manager for review. Ideally, at least five candidates should be identified for an in-person interview. 2. Formal interviews: Tailor each interview to the job opening. Use the job responsibilities and analyze the candidates to measure the specific qualities needed to perform selected duties. It’s important that the chemistry with the candidate, the company, and the onsite team are compatible. Evaluate the whole person and not just his/her capabilities to perform a task by using well-designed questions and well-developed listening skills, and exploring the candidate’s propensity to carry out the job responsibilities with particular regard to an appropriate level of compassion and commitment to productivity. 3. Reference verification: Conduct verification of licensures (if applicable) and reference checks for professional performance and personality profile to ascertain whether a candidate has those traits that make the greatest contribution to the overall success of the team. 4. Second interview: A second interview conducted with the most ideal candidates for consideration should be conducted to help make a final decision. The most critical consideration when bringing a new employee into the organization is ensuring the selection will support the program’s reputation. Once a new employee is hired, administration should foster an advantageous environment to allow the individual to excel. When possible and appropriate, orientation should include a mentoring or shadowing process. n Chris Morrison is executive medical director of Healogics Specialty Physicians, Jacksonville, FL, and medical director of Wound Systems, Atlanta, GA. Reference 1. Armstrong DG, et al. Are diabetes-related wounds and amputations worse than cancer? International Wound Journal. 2007;4(4):286-287. www.todayswoundclinic.com

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bestpractices Encouraging Leadership to Facilitate Hospital-Based Wound Care The most important component to strengthen and/or develop a facility-based wound program is by empowering staff members to assume leadership roles, preferably at all management levels. These roles should be expected of those individuals who will take the initiative to develop clinical guidelines and protocol, documentation requirements, billing and regulatory processes to ensure maximized reimbursement, ongoing education for facility staff, data measurement and reporting, and, possibly most importantly, establishing external resources through networking and community involvement so that available resources can be accessed when questions or challenges arise. When facilities cannot afford a clinical/operational expert to fulfill this roll, it may be best to seek a management or recruitment group that can provide this expertise for wound care programs.

as cleaning and preparing patient rooms and administrative medical record management? Make a list of the skills that coverage is specifically needed for, and let that guide your recruitment needs. 2.  Develop job descriptions. Once the essential duties and skill sets are known, these needs can be addressed by devising job descriptions that can be used for determining performance evaluations and making the interview/review process for candidates that much easier. 3. Determine compensation. Existing pay scales and compensation policies may already be in place, but if any changes to a position have been made these items should be reviewed. Remuneration must provide adequate incentive and be comparable and equitable with similar positions. 4. Conduct all methods of recruitment. Consider seeking candidates through Internet searches, print advertising, job fairs, and word of mouth. As we have learned more about the science of wound care and the need for an individualized and aggressive diagnostic and treatment approach to ensure best outcomes, wound care has become a physician-driven specialty. The need for physician-driven services lies at the core of the advanced practice standards for debridement, biologic dressing, hyperbaric oxygen therapy, and customized medicine such as genetic testing and compounding. Therefore, the ideal 26

wound program will be led by a physician who’s committed to continued education, comfortable with overseeing a staff and implementing best practice programs, and ensuring appropriate practice is followed. (The development of a multidisciplinary team approach can be implemented to utilize all available resources at hand.)

Evaluating Potential

When utilizing the services of a recruitment agency, hiring the best staff member becomes a crucial task and test of a wound center’s manager. Making the best hire affects a facility’s overall costs, turnover, staff relations, overall morale, and, patient satisfaction and outcomes. When the “wrong” person is hired, other staff may become resistant, morale may drop, patient care may be compromised, turnover and training costs rise, and life for the manager can become complicated. Finding good staff members is not based on whims or when “the right person comes along.” Although the hiring process can be tedious, time consuming, and even expensive at times, there is no doubt that the effort spent will be extremely beneficial. No matter how good people think they are at judging the character of others, there is a lot that goes into making a successful hire. These steps should be used: 1. Candidate screening: Review resumes and select candidates who best match the qualifications stated in the job description, and perhaps

April 2013 Today’s Wound Clinic®

22_26_TWC_April_recruitment.indd 26

conduct telephone pre-screening interviews. Select the top candidates and send those resumes to the hiring manager for review. Ideally, at least five candidates should be identified for an in-person interview. 2. Formal interviews: Tailor each interview to the job opening. Use the job responsibilities and analyze the candidates to measure the specific qualities needed to perform selected duties. It’s important that the chemistry with the candidate, the company, and the onsite team are compatible. Evaluate the whole person and not just his/her capabilities to perform a task by using well-designed questions and well-developed listening skills, and exploring the candidate’s propensity to carry out the job responsibilities with particular regard to an appropriate level of compassion and commitment to productivity. 3. Reference verification: Conduct verification of licensures (if applicable) and reference checks for professional performance and personality profile to ascertain whether a candidate has those traits that make the greatest contribution to the overall success of the team. 4. Second interview: A second interview conducted with the most ideal candidates for consideration should be conducted to help make a final decision. The most critical consideration when bringing a new employee into the organization is ensuring the selection will support the program’s reputation. Once a new employee is hired, administration should foster an advantageous environment to allow the individual to excel. When possible and appropriate, orientation should include a mentoring or shadowing process. n Chris Morrison is executive medical director of Healogics Specialty Physicians, Jacksonville, FL, and medical director of Wound Systems, Atlanta, GA. Reference 1. Armstrong DG, et al. Are diabetes-related wounds and amputations worse than cancer? International Wound Journal. 2007;4(4):286-287. www.todayswoundclinic.com

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Improving Communication in the wound clinic

Does your wound center follow these suggested strategies?

Michael Cioroiu, MD, FACS, CWS & Jeffrey M. Levine, MD, AGSF Editor’s note: There are no financial disclosures related to this article.

T

he era of pay-for-performance in healthcare is here, and payment formulas based on quality measures will soon become the standard. Because of related high-cost and high-volume adverse events, pressure ulcers have been identified by organizations such as the Centers for Medicare & Medicaid Services, the Joint Commission, the Agency for Healthcare Research Quality, and others as a quality measure across all healthcare settings. They are also sure to come under increased scrutiny as the Affordable Care Act goes into effect. Because of the interdisciplinary nature of wound care, communication is critical to maintaining the process of healing, and attention to the processes of information exchange will gain dividends in favorable outcomes and reimbursement.

Communicating to the Wound Care Patient

By nature of their various (and often multiple) comorbidities, wound care patients reside in a spectrum of healthcare settings. Communication is important for all types of chronic wounds due to a large spectrum of causation, particularly as it pertains to nonhealing traumatic or surgical wounds, diabetic wounds, arterial wounds, and those caused by venous disease. There are several avenues of communication that should be considered, all of which require attention to maintaining optimum transfer of information among providers and patients. This effort includes continuing education of caregivers and patients, and may require review of institutional 28

policies, procedures, and technologies to optimize proper “flow” of information. Clinical wound data is complex, as are the details related to description and treatment. Asking for constructive feedback is also an important part of the communication chain to ensure that instructions are transmitted accurately and effectively across all parties. Along with information related to proper nutrition and self-care of dressings and devices, communication should always include an individualized strategy for patients to manage their wounds. Gaps in the transfer of information can result in misunderstandings, misuse of products, missed follow-up appointments, and liability risk. Additionally, dissatisfied patients and families are sometimes a byproduct of inadequate communication/education. Institutions that accept transfer patients should not be subjected to “surprises” when a patient is found to have an unexpected or poorly documented wound. Research suggests that improved communication leads to not just improved patient safety and outcomes, but patient and family satisfaction and reductions in length of stay.1

Forming A Communication ‘Network’

An interdisciplinary team for wound care should be comprised of both formal (the team that functions within a wound care setting) and informal (ie, provider-to-family and physician-tophysician when located in different environments) networks. Patient networks

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can also include nurse practitioners, private practitioners, case managers, home attendants, visiting nurses, pharmacists, orthotists, physical therapists, and others. Proper communication for wound care involves transferring the right information at the right time to the right person who is capable of analyzing everything and is then able to utilize what he/she knows. Consider these six tips on how to “grease the wheels” of communication within the system of care for patients who live with pressure ulcers and other chronic wounds: 1) Caregiver to patient or family: For patients who live with pressure ulcers, they and their families require instruction regarding proper self-care management and further prevention modalities. This includes education on appropriate pressure redistribution surfaces and mobilization techniques. Patients being discharged or those who reside in the community require education on wound care, including pressure relief, dressing changes, and nutrition, as well as a ready supply of products. 2) Patient or family to caregiver: Patients should be encouraged to ask questions about their health and their wound care and should be provided with a contact number for a caregiver who is knowledgeable and readily available. If a new wound occurs or if an existing wound deteriorates, patients should be instructed to immediately notify their caregivers so that new, worsening, or underlying medical problems that require investigation and/or immediate treatment can be considered. www.todayswoundclinic.com

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A


bestpractices 3) Nurse to physician and physician to nurse: Nurses and physicians are often locked within their respective “silos” and sometimes do not communicate in a timely manner, but physicians need to be aware of any deterioration in skin condition immediately. Skin problems such as moisture-associated dermatitis and stages I and II pressure ulcers are often not communicated to a physician because they only require nursing interventions according to a facility’s policies. This is potentially troublesome if the physician does not properly examine a wound. A physician’s wound care instructions must be timely, legible, and complete. Specific information must be present on wound care orders, such as location of the wound, type of dressing, and frequency of application. 4) Physician to physician: Pathologic conditions regarding skin should be documented and communicated along the continuum of care. Skin care has often been delegated to nurses, a philosophy that is no longer applicable in today’s risk-management and patient-centered environment. Different medical specialties

may have alternative views on issues such as wound classification and treatment, and these should be openly discussed to facilitate the best collaborative approach to wound healing. Discharge summaries are critical documents that physicians rely upon for comprehensive information on a hospital stay, yet they often lack information on wounds and wound care. If a patient develops a wound during a hospital stay, this should be listed in the discharge summary along with current treatments, prescriptions, and follow-up appointments with wound specialists. 5) Facility to facility: Information concerning wound-specific documentation and treatment must accompany patients when they are referred across the healthcare continuum.When patients are transferred between facilities, it is critical that accurate wound care information accompany them. The risk-management environment has brought attention to documentation discrepancies between hospitals and nursing homes, which may reflect directly on quality-related issues. Patients should have a total skin assessment when being discharged and

upon arrival at any facility. This also applies to the visiting nurse who begins a course of home services. This enables caregivers to be informed of critical issues such as obtaining proper prevention devices and promptly continuing the appropriate treatments. 6) Proper use of technology: Proper design and implementation of a wound care electronic health record (EHR) can bring the patient and caregiver network together and fill potential gaps.The EHR can provide comprehensive take-home information that the patient or caregiver can use when going from provider to provider. There is also the possibility of web-based, password-protected information that can enable different providers to access wound care information. n Michael Cioroiu is co-director and Jeffrey Levine is a staff physician at the Center for Advanced Wound Care at Beth Israel Medical Center, NY. References 1. P  reventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care, Agency for Healthcare Research and Quality. Accessed online at www.ahrq.gov/research/ltc/pressureulcertoolkit/ putoolkit.pdf.

When diagnosing infection in a chronic non healing wound…

Are you seeing the entire picture? Biofilm based wound care 28_29_TWC_April_woundcare_commun.indd 29

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Diabetes Screening in the Wound Clinic: Reader Survey Results Today’s Wound Clinic recently polled readers to gauge their clinics’ habits regarding diabetes screening and education. Here’s what we found.

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ast month, Today’s Wound Clinic featured a comprehensive series of articles related to the management of diabetes within the wound clinic — from clinical issues such as the cardiovascular effects of diabetic foot ulcers to the importance that wound clinic providers should recognize in conducting routine glucose screening and education on nutrition and other disease-management concerns. This month, as part of our special focus on best practices, we present our readers with the results of an anonymous survey we conducted by polling our readers (your peers) about how well wound clinics may or may not be providing screening and following up on their patients’ diabetes management after discharge. More than 140 wound care clinicians participated in the survey, which produced some surprising and intriguing results.

Diabetic Screening: Not A Given?

Despite the high prevalence that diabetes plays in wound centers across the US, 69.5% of survey respondents said they do not screen those patients who are living with chronic wounds for the possible presence of undisclosed diabetes (Figure 1). Likewise, an even greater majority (77.1%) doesn’t screen all patients known to be living with the disease for comorbid clinical depression (Figure 2), even though those who are diabetic have a greater chance of developing depression. (However, most in this patient population are said to not be living with this comorbidity, according to the American Diabetes Association.) Still, what is the wound clinic’s responsibility to screen for the presence of 30

these conditions? According to Caroline Fife, MD, FAAFP, CWS, medical director of St. Luke’s Wound Clinic, The Woodlands, TX, and editorial board member of TWC, “these are the questions you need to ask in your clinic because if you don’t know the answers, you’re not involved enough in the patient’s care.” Despite these numbers, most wound clinics are at least tackling the issue of compliance among the diabetes population, according to this survey, as 87.3% report assessing adherence to overall diabetes management through screening (Figure 3). Still, finger-sticking for blood glucose checks does not appear to be one of the predominant screening measures. Only 30.6% of respondents report checking patients’ blood glucose at each visit (Figure 4) while others claim to do so only when symptomatic (15.3%; Figure 4) or only during initial visits (4.2%; Figure 4) or even randomly (7.6%; Figure 4). Despite these low numbers, the advantages of glucose finger-sticking have been proven affective when integrated into daily protocol, according to Tere Sigler, PT, CWS, CLT-LANA, clinical director of the Archbold Center for Wound Management at Archbold Memorial Hospital, Thomasville, GA.1 When it comes to checking hemoglobin A1c on all chronic, nonhealing wound patients, the numbers are better, with 58% responding affirmatively (Figure 8).

Availability of Certified Diabetes Educator

While the opportunity to be proactive and comprehensive when it comes to screening wound care patients and

April 2013 Today’s Wound Clinic®

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following up with them and their providers as they move along the care continuum may individually be determined on the initiative of each clinic, financial and administrative obstacles may play a part when it comes to providing patients with a certified diabetes educator (CDE). According to 64.6% of survey respondents, their clinics do not feature the services of a dedicated CDE or dietitian, while only 17.4% can offer the advantages of having both on staff (Figure 5). However, 67.2% of those without a dietitian and/or diabetes educator report making referrals for patients to visit one or both (Figure 6). This may be encouraging, but on the flipside are the 33.1% of wound care providers among survey respondents who do not support these referrals with distribution of their own educational materials (Figure 7). According to Sigler, who is also a member of the TWC editorial board, wound clinic staff should be diligent in their diabetes education distribution whether or not they employ a CDE. “We (as wound care providers) need to conduct diabetes education in our clinics because of the repetitiveness in which we see these patients,” she said. “That means you don’t have to get someone to process all the information at once. The wound clinic is a great setting to provide diabetes education, but the reality is that it’s not everyone’s first priority. And when things get busy the education part can fall off the radar.” n References 1. S igler, T. Monitoring blood glucose values in the wound clinic: An aggressive approach to diabetes management. Today’s Wound Clinic. 2013;7(2):18-19. www.todayswoundclinic.com

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bestpractices Yes, patients screened for potential diabetes during each visit 30.5%

No 77.1% Yes 22.9%

No 69.5%

Figure 1

Figure 2

Do you screen chronic wound patients who don’t have existing comorbid diabetes for the presence of undisclosed diabetes during each visit?

Do you screen all your patients who live with diabetes for clinical depression?

Only DNA analysis can show the entire population of infectious materials in chronic wound biofilms, including anerobes, mold, and fungi.

Diagnostic tools with DNA level certainty empower personalized medicine in wound care. Clinicians can now confidently manage the microbial reality of each patient’s bioburden through fully certified, collaborating DNA diagnostics labs. Results comprehensively and quantitatively define the true microbial wound census (bacteria, yeast & fungi). An expert clinical consultation follows to enable an Rx order of patient specific LipoGel® Rx.

Targeted therapy, with DNA level certainty.

Traditional lab culture can grow less than 5% of the known pathogens, leading to a diagnosis and treatment plan based upon incomplete information. Clinical results in ~ 1400 patients, DNA targeted topical treatment vs. systemic antibiotics Culture Systemic 100%

% Healed (Full Closure)

90%

DNA Dx/Systemic

Doubled healing rate in every period!

90%

89%

86%

73%

70% 59%

60%

47% 38% 32%

60%

62%

54%

53%

50%

30%

Wolcott RD, Wound Healing Society April 2011

DNA Dx/Topical

81%

80%

40%

• 99% of chronic wounds are polymicrobial, with high abundance. • < 5% of known wound microbes can be readily grown in culture. • 97% of chronic wounds contain these “easily grown” microbes at < 1%. • The limitations and inadequacies of traditional culture routinely lead to empirical therapy, largely ineffective for the microbial reality.

43%

45%

48%

31%

22%

20% 30 days

60 days

90 days

120 days

150 days

206 days

Days from Enrollment Journal of Wound Care 2011; 20: 5, 232.

30_32_TWC_April_Diabetes.indd 31

1004 Garfield Drive, Bldg 340

Lubbock, Texas 79416

806-771-1134

www.pathogenius.com

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bestpractices Random finger sticks for blood glucose are conducted

No 12.7%

29.8%

30.6%

Only in hyperbaric patients Only if the patient is symptomatic

4.2%

Yes 87.3%

15.3% 12.5%

7.6%

Only during the initial visit No Yes, blood glucose is checked during each visit

Figure 3 Do you screen all wound care patients who live with diabetes (including those without existing diabetic foot ulcers) to assess adherence to overall diabetes management?

17.4%

Figure 4 Do you always check finger-stick blood glucose in all patients who live with diabetes who are seen at your wound clinic?

22.4%

Yes, certified diabetes educator

6.9%

64.6%

11.1%

67.2%

Yes, dietician Yes, certified diabetes educator and dietitian

10.4%

Yes, if they have an existing DFU Yes No

No

Figure 6

Figure 5

Does your wound clinic have a dedicated certified diabetes educator and/or dietitian on staff?

If you do not house a certified diabetes educator or dietician, do you refer your patients who live with diabetes somewhere to receive diabetes education?

No 42%

No 33.1% Yes 58%

Yes 66.9% Figure 7

Do you distribute educational materials that explain how diabetes affects wound healing to all patients?

32

Figure 8

Do you always check hemoglobin A1c on all chronic, nonhealing wound patients who live with diabetes?

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clinician’sreport Kinetic Concepts Inc. (KCI), San Antonio, TX

NPWT: Powered & Non-Powered

patient presentation.

Can you “Y” wounds together? If so, how many? Yes,

ActiV.A.C. can be used to “Y” two wounds together if they FOUNDED: 1976 are of the same etiology. How many NPWT products does your company produce? Five: ActiV.A.C.® Therapy System, InfoV.A.C.® Therapy Sys- How do you handle undermining? V.A.C. WhiteFoam tem, V.A.C.® Freedom Therapy System, V.A.C.Via™ Therapy System, and, most recently,V.A.C.Ulta™ Therapy System.

What is your most popular NPWT product? ActiV.A.C.

Dressing may be placed in undermined areas with good foamto-tissue contact with minimum pressure setting at -125 mm Hg.

How often do you handle fistulas? When involving enWhat makes this product unique? 93% of all NPWT pub- teric fistula, it’s recommended to seek expert support.V.A.C. ®

lished evidence is based on V.A.C. Therapy Systems.

What is the product’s impact on patient care? Clinical studies have shown V.A.C. Therapy is associated with lowered incidence of readmission, additional surgeries, and complications; fewer secondary amputations; reduced healing time; reduced costs in acute and post-acute settings; reduced risk of hospitalization; and reduced nursing time.

What is the suction pressure or range of pressure? The user-selectable negative pressure range is between -25 and -200 mm Hg, with the pressure-setting selection being left to physician discretion.

Is the pressure pre-set? Yes, to -125 mm Hg and continuous therapy.

Can this be changed? Yes. Is there an intermittent feature? Yes.

Therapy is contraindicated for use with non-enteric and unexplored fistulas.

How do you handle exposed tendon or bone? Tendons, ligaments,and nerves should be protected to avoid direct contact with V.A.C. Dressings and can be covered with natural tissue or meshed, non-adherent porous material or bioengineered tissue to help minimize risk of desiccation or injury. Bone may be protected with a single layer of a non-adherent interface.

How is your device billed? ActiV.A.C. and V.A.C. Freedom Therapy are rented and typically billed to the patient’s insurance, depending on eligibility and coverage. Contact: 800-275-4524; media@kci1.com; www.kci1.com. n

Spiracur Inc., Sunnyvale, CA

Is there a cutoff that stops suction if the canister is FOUNDED: 2007 full? Yes. Product: SNaP® Wound Care System Is there a one-way valve to prevent fluid from coming back through the tubing toward the patient? No; Does your product operate without electricity or however, there are safety features that mitigate retrograde flow batteries? Yes, SNaP is mechanically powered. toward the patient.

How long does the battery last? When fully charged, 14 Does your product operate silently? Yes. hours, on average.

How much does the machine weigh? ActiV.A.C. is fully portable and weighs 2.4 lbs when the 300 ml canister is empty.

Is your product ultraportable? Yes, it is pocket-sized. How much does your product weigh? 2.2 oz.

What is the interface with the wound? Specialty V.A.C. Does your product include advanced wound dressing? Dressings are available to be placed directly at the wound site to facilitate negative pressure application.

Yes, it has a proprietary hydrocolloid dressing that may reduce periwound maceration and allows for easy removal.

How often do you recommend changing the dressing? Does the contact layer have antimicrobial properties? In a monitored, non-infected wound,V.A.C. Dressings should be changed every 48-72 hours, but no fewer than three times per week, with frequency adjusted by the clinician as appropriate. For infected wounds, dressing change intervals should be based on continuing evaluation of wound condition and

Yes, SNaP provides a choice of blue foam or antimicrobial gauze that contains 0.2% polyhexamethylene biguanide.

What levels of negative pressure Are delivered? 125 mm Hg, 100 mm Hg, and 75 mm Hg pressure settings.

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clinician’sreport Is there a cutoff that stops suction if the canister is full? Yes. Is there a one-way valve to prevent fluid from coming back through the tubing toward the patient? Yes. How do you handle wounds in challenging locations? SNaP Dressing is customizable and can be cut to fit a variety of anatomic areas. In addition, the SNaP SecurRing™ Hydrocolloid can be used with the SNaP System to facilitate fast and easy dressing applications by filling uneven skin surfaces and molding around challenging body contours, such as toe amputations and heel wounds.

How often do you recommend changing the dressing? SNaP requires two dressing changes per week.

Have you conducted any clinical studies with your product? Yes, we have completed a 132-patient comparative, randomized-controlled study demonstrating non-inferiority to powered NPWT in wound-healing outcomes. In addition, patient survey data found improved quality of life in areas such as mobility, social interaction, and sleep.

Is your product available off-the-shelf? Yes. Is your product disposable? Yes. Is your product reimbursed in wound care centers and physician offices? Yes, SNaP is covered under G0456 and G0457 for clinical services using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical applications(s), wound assessment, and instructions for ongoing care.

Contact: 877-774-7228; info@spiracur.com; www.spiracur.com. n

What is the product’s impact on patient care? Medela’s products combine the positive clinical outcomes of NPWT with the advantages of simplicity and mobility. Invia Liberty and Invia Motion devices, wound dressing kits, and accessories are easy to use in all caregiving environments, provide patients with greater mobility, and offer healthcare professionals flexibility in therapy management. How is your device billed? Devices and accessories are distributed to hospitals, long-term care facilities, and home care settings through our PartnerFirst™ program that works in determining patient eligibility and performs third-party billing.

Contact: 877-694-6842; suction@medela.com; www.medela.com. n

Smith & Nephew, St. Petersburg, FL Founded: 1856 How many NPWT products does your company produce? Seven, including RENASYS™ GO, RENASYS EZ Plus, and PICO,™ a pocket-sized, single use NPWT system.

What is your most popular NPWT product? There has been strong interest in PICO since it received FDA market clearance in 2012. What makes this product unique? PICO combines ease of use with revolutionary dressing technology that eliminates bulky canisters. A high-moisture vapor transpiration rate top film allows one-way transpiration of exudate vapor. A proprietary absorbent layer moves exudate away from the wound and initiates evaporation, and an airlock layer maintains open airflow and allows even distribution of negative pressure across the dressing.

Medela Inc., McHenry, IL

What is the product’s impact on patient care? PICO is

Founded: 1961

Any Special Recommendations for high bioburden or infection? ACTICOAT™ Flex, a soft and flexible antimicro-

How many NPWT products does your company produce? Two: Invia® Liberty® and introducing Invia® Motion.TM

What is your most popular NPWT product? Invia Liberty and Invia Motion NPWT systems.

What makes this product unique? Invia Liberty and Invia Motion can be used across all care settings. Invia Liberty’s innovative design delivers flexibility in treating acute and chronic wounds. Invia Motion is a personal pump that enables patients to participate in normal daily activities while providing therapy throughout the period of treatment. Both systems can be used with gauze or foam dressing kits. 36

simple to learn, apply, and operate.

bial barrier dressing, can be used in conjunction with PICO.

How is your device billed? “G” codes 0456 and 0457 may be used by providers submitting claims for PICO use. The amount for hospitals billing in hospital outpatient ambulatory payment classification is $209.65.This payment is separate from the Medicare physician payment. Hospital outpatient payments in higher-cost areas such as San Francisco and New York City may be higher, possibly in the range of $250-$270. Contact: 888-711-9903; reimbursement@smith-nephew.com; www. smith-nephew.com/reimbursement. n

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facilityinfocus Creating a Collaborative Wound Care Continuum Main Line Health’s outpatient program is progressively changing the face of wound care throughout the hospital network.

By Joe Darrah ing wound care programs available in the Philadelphia region.” As she and her staff members attest, it’s a program born out of a collaborative effort to remain comprehensive in care, reliant on the support of the interdisciplinary staff, dedicated to providing education and follow-up communication with primary clinicians, and committed to the processes put into place. It’s also the result of a meticulous approach to wound care that’s apparent even to the extent of how the Bryn Mawr center was originally mapped. THE WOUND TEAM: Members of Main Line Health’s wound care staff include (from left): Mary Behler, RN; Rebecca Witham, MD; Sharon Lynn Hannum, RN; Jeannine Sorenson, RN; Pam Beideman, RN; Debbie Raap, PCT; and Brenda Shantz, RN.

B

ryn Mawr, PA — Give her 90 days, and Sharon Lynn Hannum, RN, will tell you she can devise, design, and launch a hospital-based outpatient wound care center from the ground up. Give her nine months, as did the administration at Main Line Health, one of suburban Philadelphia’s most comprehensive hospital networks, and you get what you bargain for — the foundation for a program that is systematically revamping the structure and delivery of wound care across the entire health system. Recruited to the Main Line’s Bryn Mawr (PA) Hospital in 2003 to establish an outpatient wound-healing center at the Magnet facility to target a local patient population predominantly being treated in the primary care arena, Hannum’s center has met this accomplishment and then some.With a progressively increasing patient caseload that has been on the incline since the doors opened (the center recorded 3,000 visits in 2012), the wound care program has also proven

cost-effective through the establishment of a structured protocol that has since begun to be implemented throughout the hospital system’s reach along Philly’s western suburbs into Paoli (PA) Hospital. Predicated on a philosophy that utilizes a multidisciplinary wound care staff jointly trained on a collaborative procedural approach that allows consistent patient care, product usage, and electronic health record (EHR) optimization within multiple facility sites, the program, as it nears full integration, also allows patients to experience the same clinical and follow-up services provided by the same healthcare staff within the network — regardless of where they receive care. “It’s a superior patient experience,” said Hannum, a wound care nurse of nearly 20 years with an extensive background in formulating and operating outpatient hospital wound departments along the metro regions of Philadelphia, New Jersey, and New York. “I honestly think we have one of the best function-

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A Collaborative Blueprint

Laying out the plans for what would eventually become a 3,600-square-foot outpatient center took the intricate consideration of determining where entrances and exits should appear to allocating for an appropriate number of examination rooms and having the foresight to allot enough space for what would become a busy hyperbarics suite (which averages 3-4 patients per week today), all of which Hannum played a role in. With additional time afforded to the opening of the wound center as the hospital awaited the relocation of a breast health center that had occupied the wound center’s future space, Hannum had that much more opportunity to “get her hands dirty.” “We knew we would need enough exam rooms so that patients wouldn’t have to wait long in our reception area,” she said. “It’s one thing to wait in a lobby, it’s another thing to have the access to your own room to wait. If you only have two exam rooms to offer and you have four people scheduled in an hour’s time, somebody’s going to be waiting at reception for a while. I wanted to make sure we designed a center that considToday’s Wound Clinic® April 2013

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facilityinfocus ered patient flow.” With five exam rooms available (four for ambulatory patients, one that’s big enough to house a stretcher), Bryn Mawr was also designed to have the capacity to handle non-ambulatory and non-emergency cases. “One of the most important decisions we made when we designed our center was to provide space for stretchers to come in through a back entrance that leads right into our biggest exam room,” Hannum said. “You might have someone come in with a sacral or hip wound where they can’t be in a normal exam chair, so having a bed and having the ability to open the back door so stretchers don’t have to come through the waiting room, where we often have obstacles like people in wheelchairs or on crutches, makes things that much more convenient for the patients and the staff.” Another crucial logistical step taken during the design phase was reserving space for dressing rooms for hyperbarics patients. Originally operating with one chamber, the center added a second (bariatric) chamber six months after opening, an upgrade Hannum said she anticipated but needed the patient visit numbers to prove themselves in order to justify the acquisition. “Knowing the amount of square footage we would need to fit enough exam rooms and a hyperbaric area was very important,” Hannum continued. “You need to know where your equipment is going before you get it.You need to know where your furniture is going. Knowing we wanted to have more than one hyperbaric chamber, we needed enough clothing rooms so that patients could come in and change in privacy while we still had patients in the chambers.” Also not to be neglected was Hannum’s vision of the appropriate wound care staff, which includes a panel of eight physicians from a multitude of specialties including podiatry, general surgery (see sidebar on page 42), internal medicine, plastics, and vascular care as well as a nursing staff that today has grown to seven members among the Bryn Mawr and Paoli centers. One of the first clinicians to volunteer for a position within the outpatient center was Daniel Westawski, MD, FACS, a plastic surgeon who had already been on staff in Bryn Mawr’s inpatient wound department at the time the outpatient center began construction.Though he stands by the wound care that had traditionally been performed at the hospital, Westawski, who also owns three private practices within the outlying region, admits that the need for a devoted outpatient center was real and that the challenge to give patients the dedicated, specialized care they deserved had become too daunting. “Before the outpatient center opened, everyone, including internal medicine and general surgeons, would try to manage wounds on their own,” he related. “They’d call in plastic surgeons like myself to assist, but that was hard to do from a private practice standpoint because wound patients specifically require a lot of care and follow up. They require a lot of medical resources and a lot of time that, in private practice — no matter the specialty — you’re just not typically equipped to do to the degree you need to.” However, securing the trust of area physicians to send their 38

Undergoing Wound Care, Together Some “serendipitous” healthcare complications lead one Philadelphia-area couple into neighboring hyperbaric chambers. By Joe Darrah Bryn Mawr, PA — Since the day they met more than 60 years ago, the lives of Augustus Michael (Gus) and Lee Iatesta have, quite literally, been defined by coincidence. Recently, Gus and Lee Iatesta so too has their healthcare. It was the spring of 1952 when Lee was approached by her parents about a young doctor, the son of a couple they knew through a local Sons of Italy club based in the Philadelphia suburbs, whom they wanted to introduce her to. Already dating someone at the time, Lee wasn’t interested in being set up, so she shrugged it off. Unbeknownst to Gus, who just so happened to make an appearance at a Sons of Italy dance on an otherwise uneventful Friday night for he and a few friends that Lee was also at, he’d end up introducing himself upon his arrival, asking her for a dance. She obliged, and by the time Lee’s parents put one and one together for her later that evening, she was already smitten. “It was just so coincidental that we met on our own like that, but the rest is history, because I ended up taking him to my junior and senior proms, and we married two years later,” said Lee, who recently completed several weeks of hyperbaric therapy at Bryn Mawr (PA) Hospital’s Wound Healing Center due to a compromised bladder following radiation treatment for cervical cancer. Having been previously recommended for hyperbaric treatments by his urologist a few years prior after developing minor radiation proctitis as a side effect to prostate cancer treatments, Gus had been hesitant about undergoing the therapy. With the proctitis condition doing little to impact his quality of life, he had decided against hyperbarics because of the weeks-long commitment he was told it would take to achieve full wound closure. However, when Lee was informed that hyperbarics was the only option she had to close a hole in her bladder that registered the size of a half dollar, Gus began to see the procedure in a new light. “I figured, if my wife had to do it and I could benefit from it, we might as well do it together,” he said. After more than two months of treatment sessions, both are fully healed.

Road to Recovery Prior to the hyperbaric treatments, Lee’s condition had become very severe. Saddled with catheters on each kidney, her bladder would not function on its own and life had become very painful, not to mention uncomfortable. She

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facilityinfocus patients into the Bryn Mawr center would not be as easy as anticipated.

Reliance on Referrals

Although the outpatient center had patients essentially waiting in the wings due to referrals coming from its own physician staff members such as Westawski and Robert C. Floros, DPM, a podiatrist who also owns multiple private practices in the region who previously worked with Hannum prior to joining Bryn Mawr in 2003, establishing a reputation as a referral center would take some time as well as a delicate political approach. “Even when considering that making referrals would be a way to defray costs for primary providers and that many of them don’t have the staff to handle wound care patients coming into their offices on a weekly basis or the inventory of supplies required to manage chronic wounds, some of the area physicians were a little leery of us at the beginning — they didn’t want to ‘lose’ their patients to us,” Hannum said. As a referring physician himself, Westawski said earning the physicians’ trust and their referrals came down to initiating communication with each provider to inform them about the structure and benefits of their services as well as their intentions to keep an open line of communication regarding all aspects of wound care that could impact other comorbidities. “And by doing that we’ve been very well received in our community,” Westawski said. “The providers are happy to work with us as a team because we make sure we collaborate with them frequently by asking for their help in managing the patients’ overall health, particularly related to diabetes, congestive heart failure, or chronic renal deficiencies, while we’re trying to get their wound closed. Even before something as simple as a lymphedema pump, we’ll check with the patient’s cardiologist to make sure it’s not going to cause unforeseen stress on their heart. These physicians don’t want their patients needing more healing time than necessary.And we have a coordinated team of clinicians that referring physicians know have the time to devote to their patients.”

Coordinated Collaboration

Wound Care Patient Profile (continued) underwent surgery in an attempt to repair her damaged bladder, but due to her age and radiation treatments, the bladder wall had become too thin to seal. Sensing how fearful Lee had become from the multiple procedures and the lengthy hyperbaric regimen she would need to undergo, Gus didn’t want her to go through anything alone. They were both relieved to learn that the wound care center at Bryn Mawr, less than a 20-minute commute from their home in Broomall, PA, could not only treat them both but allow them to do so side-by-side in neighboring chambers. For more than two months the couple spent the middle of their afternoons together in the wound center. Though Lee’s 40 prescribed treatments outnumbered Gus’ required 35, he’d accompany her through the duration of her visits — often spending some downtime getting to know their caregivers better. “It was one of those serendipitous things that you can’t say you ‘enjoyed’ doing, but it was nice to be able to support each other,” said Gus, a retired optometrist who also underwent open-heart surgery this past July for an aortic valve replacement and two bypasses (as well as the subsequent cardiac rehabilitation, which frequently overlapped with his hyperbaric therapy). “The care we received exceeded our expectations. We got to know all the physicians and all the staff, and everyone was very courteous — we had absolutely a completely positive experience.” The couple know a bit about serendipity. Aside from how they met, their daughter met her husband, a Frenchman, while working at a convention in New Orleans several years ago. She, a manager for a company that operates national medical conventions and he, an engineer who was visiting the US in hopes of securing a research grant, didn’t have much time to get acquainted before he had to return home. However, when that grant ultimately came through from Philadelphia’s Drexel University, the two had a chance to reconnect. Today, they’re married, living in France, and the Iatestas can say they have five bilingual grandchildren. “After the initial shock of her moving,” Lee said, “I told myself she could just as easily have met someone from Iowa or Illinois and moved there; but I’d much rather land in Paris and see the Eiffel Tower when I go to visit her.” With their health back on the mend, frequent travel has again become part of life for the Iatestas, whose regular travels have also seen them visit Italy, Spain, Sardinia, the Caribbean Islands, China, Singapore, and Iceland. Speaking with Today’s Wound Clinic on the heels of Lee’s most recent urologist visit in early March, the couple was ready to celebrate her recent clean bill of health. Their plans for spring included an annual trip to Florida, where they’ll spend several weeks enjoying each other’s company, relaxing, and maybe taking in a movie or two together outside the confines of a hyperbaric chamber. “It’s been a tough year, health-wise,” Gus said. “Hopefully, we’ll have some time out of the hospital now for a while.” n

That team, aside from being comprised of specialists who represent a wide range across the healthcare spectrum, is know for the depths of experience that it collectively possesses, especially as it pertains to wound care. Floros, a fellow of the American College of Foot and Ankle Surgeons who has spent nearly 30 years in podiatric practice, has been providing wound care, as he puts it, “since before it became popular.” “In our field of foot and ankle reconstruction, we’ve been providing wound care since day one,” said Floros, who’s spent the last 20 years of his career specializing in wound care. “I refer my patients here directly. The excellence and quality of the care here is something that I’ve never seen in my 28 years of experience. It’s just tremendous.” 40

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facilityinfocus Like Westawski, Floros assisted in the opening of the Bryn Mawr center, up to and including his involvement in the ordering of supplies and equipment.With his surgical background, he’s often brought in to consult on any wound below the knee, which makes up an estimated 60 percent of the program’s population. He said the collaboration between physicians and nurses begins prior to the initiation of any care planning. “We’ll talk amongst each other about the diagnosis of the systemic disease that might be causing the wound or the trauma that might have caused it, and deal with the ramifications of that — whether it’s malignment, or the need for fusion or debridement and wound healing, or helping with referrals and establishing the network and team concept with the vascular specialist, neurologist, plastics, internal medicine or renal,” Floros said. “After a patient has been examined and we’ve determined as a team the diagnosis and reason for their wound, we’ll plug them into the specialties they need. There’s a lot of referral in the system, and the collaboration between our center and other specialists has really helped our patients tremendously as far as exponentially improving healing rates and the success rate in reducing amputations. It’s a nice luxury for patients to have in the system.” (See patient sidebar on page 37). Beyond open communication, the staff utilizes an EHR system that was implemented in 2012 and has become uniform within multiple Main Line locations. Based on the progress experienced at Bryn Mawr, Hannum was approached by health system administration to oversee the wound care program at Paoli. “It was a great opportunity for me to foster collaboration, peer review, and coverage amongst both sites,” said Hannum, referring to a peer-review process she enacted at both sites that helps ensure protocol is carried out consistently at all times — even to the point that registration remains accurate and that all pertinent patient information is collected prior to clinical assessment. “We took what was working at Bryn Mawr and came to Paoli with it, and we began to realize that we’re not just silos in a system — we’re 42

a proven wound-healing and hyperbaric program that’s expanding throughout the system.” The enhanced service at the Paoli site have long been realized, according to Pamela Beideman, RN, a wound care nurse on staff at Paoli who has been with the hospital 28 years (the last seven specifically in wound care). While correlation has always existed between the two centers, Beideman said the impact of the official merger has been significant. “It’s more uniform today — we utilize staff between the two units and coordinate our educational programs, patient care, and products being used,” said Beideman, whose extensive healthcare background includes med/surg, oncology, gastrointestinal, outpatient surgery, endoscopy, and critical care. “There’s more continuity between the units, so patients are able to have a more pleasant experience if they need to visit both locations.” Not only has the ability for patients to undergo care simultaneously become a possibility, it has become reality for many patients within the system, Beideman said. “We encourage our patients to accommodate whatever their schedules may be by receiving treatment at multiple centers so that there’s no break in their treatment,” she said.

Future Expansion

In preparation for the wound care program’s expansion across Main Line Health, Hannum has started forming an affinity wound care group that’s responsible for meeting regularly to evaluate products, policies, and procedures as expansion progresses. “If you’re not collaborating, you’re missing out on the sharing of ideas, sharing of supplies — just the general cohesion of policies, protocol, and patient care,” Hannum said.“For the patient’s peace of mind and potential for better outcomes — it just makes more sense. Our patients can feel confident and comfortable that there’s always someone here to care for them who has the knowledge and information related to their care in particular.” n Joe Darrah is managing editor of Today’s Wound Clinic.

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A Global Wound Care Perspective Forced into permanent US residency due to civil unrest back home, an Iranian physician joins the wound care ‘revolution.’ By Joe Darrah Bryn Mawr, PA — Upon leaving his native Persia for the US in the mid-1970s, Manoucher Afshari, MD, FICS, FACS, had Manoucher Afshari, his career, his life all MD, FICS, FACS mapped out. Having already earned his professional doctorate in medicine, he wanted to do the same in the US and bring that knowledge and skills back home. But as he finished his education at the turn of the new decade, the Iranian Revolution was in full swing — political and social unrest posing threats to safety. At the urging of his family, he decided to “keep his distance for a few months.” Twenty-three years later, he’s still here, carving out an extensive healthcare career that recently led him into wound care, which has also seen great change in the time since Afshari entered this country. “After about three years went by and home was still the same with chaos, I had to look around at my children growing and realize that this is where me and my family were staying,” said Afshari, one of eight physicians at Bryn Mawr (PA) Hospital’s Wound Healing Center. “I am very thankful and fortunate to be here still.” Putting off random urges to retire over the years, he’s proven to be an asset to the outpatient wound program at Bryn Mawr due to an extensive healthcare background that he said greatly lends to the care of his patients. A member of the Bryn Mawr staff since October, Afshari spent more than eight years in residency during the 1980s, including general surgery, trauma surgery, cardiac surgery, and kidney

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industryinsider An Inside Look at ACell Inc.

F

or this month’s feature, Today’s Wound Clinic spoke with Arjun R. Ishwar, product manager.

Today’s Wound Clinic (TWC): How long have you been in wound care, and how did you enter this area of healthcare? Arjun R. Ishwar (ARI): ACell has been in Arjun R. Ishwar product manager the wound care arena for nearly four years. I began my role as a clinical consultant within the dermal scaffolding field for major burns and trauma. TWC: What’s your day-to-day role? ARI: As product manager of a quickly growing regenerative medicine company, I identify clinical needs and work with a multidisciplinary team to develop and commercialize innovative products that help physicians and their patients. On a daily basis, my challenge is to merge marketing and clinical needs and increase sales. TWC: What do you find most rewarding about providing for your industry? ARI: We have been rewarded with the ability to touch a great number of lives. It is our goal to continue to impact the medical field with a technology that is unprecedented. TWC: How would you describe the overall mission of your company? ARI: ACell is committed to provid44

“The future of ACell holds enormous promise.” Arjun R. Ishwar ing high-quality products that positively change patient care. TWC: What’s new with your company in 2013? ARI: ACell is on the leading edge of medical device technology. In 2013, ACell is planning to introduce products for new indications that will immediately impact patient care. TWC: How is your company unique? ARI: ACell offers a proprietary technology in the form of unique extracellular matrix products that repair and remodel damaged tissues. ACell’s flagship product, MatriStem,® has applications ranging from abdominal wall reconstruction to chronic wound closure. TWC: Why are you passionate about the work of your company? ARI: The most touching moment of my professional career was observing a patient survive a “code” in the operating room. After resuscitation, ACell was used to help the patient.Today, the patient lives a healthy and fulfilling life. Our product changes lives.

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TWC: How is your company approaching challenges in wound care? ARI: MatriStem devices have been used successfully, often in situations when all else has failed. While certain hurdles exist in the ever-changing healthcare market, ACell is proactively researching and conducting clinical trials that demonstrate superiority. TWC: What are your most popular products and/or services? ARI: MatriStem MicroMatrix® is a product completely unique to the market. For this reason, physicians around the country have adopted this product into modern practice for a multitude of advanced wound care procedures. TWC: How do you ensure proper training on products and services? ARI: ACell is committed to the education of its personnel and for the medical professionals we serve.The company has increased our commitment toward professional education significantly and hosts training events frequently. TWC: What are the future goals for you and your company? ARI: The future for ACell holds enormous promise. ACell will be the recognized leader in regenerative extracellular matrix technology, offering superior healing options for doctors and patients. We are dedicated to creating high-quality, innovative solutions that we believe will transform standards of medical care, improving the quality of life of patients. ACell is committed to becoming and remaining an innovative leader in regenerative medical technology. n www.todayswoundclinic.com

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109 Bayou Perez Drive madisonville, LA 70447

032813-Matx-HalfPg.indd 1

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ComING SooN!

SAWC SPRING APP The Premiere Wound Care Conference at Your Fingertips SAWC Spring introduces its Conference Mobile APP to allow attendees to have mobile access to conference activities by a simple touch of their smartphone. The APP will be available FREE on Apple App Store and GooglePlay.

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transplant surgery. In order to maintain a valid visa during this time, Afshari said he had to remain “in training,” so he kept broadening his scope of practice.   in the United Sates and “At that point I was determined to stay learn as much as I could, even if that meant that I would ‘retire’ one day as a resident,” he said, somewhat   in jest. “I came to the US because I wanted to be a surgeon, and this was and still is the best place to learn how to practice medicine.” At the age of 40 in 1982, he opened his own general and vascular surgery practice while working as a trauma surgeon. He’d do so for 10 years before relocating north to Maine in the early 2000s during a time in Pennsylvania when many physicians closed or relocated their practices due to high insurance costs. Further expanding on his skills in the “Pine Tree State,” Afshari spent eight years practicing as a general surgeon in a rural, 15-bed hospital. The more patients he began to care for who lived with chronic, nonhealing wounds, the more his interest in specializing in this field became piqued. Today, he’s a fellow of the American and International College of Surgeons and serves as clinical associate professor at Temple University in Philadelphia, where he instructs residents and medical students. His curriculum includes wound care, which he said he continues to gain an increased appreciation for. “In general surgery, you know certain physiology of wounds but you don’t always realize how much a wound center can help your patients heal their wounds,” he explained. “When you’re talking about patients who’ve had wounds for many years, something’s missing in their overall care and their health. So I’ve tried to bring my expertise and combine it with treatments that we use in the wound center to help our patients heal.”

Here To Stay At Bryn Mawr, Afshari works among an interdisciplinary physician and nursing wound care staff that includes podiatry, general surgery, internal medicine, plastics, and vascular care. Through a care philosophy that stresses collaboration and a uniform protocol that has been clearly defined and implemented into a universal electronic health record, Afshari and his colleagues are changing the way wound care is conducted for many people living in Philadelphia and its surrounding suburbs. Launched in 2003, the wound-healing program at Bryn Mawr has since extended into the company’s Paoli (PA) Hospital. Afshari said the collaboration within the wound program serves as the basis for the improved wound healing and amputation rates that the network is seeing. “There’s harmony in this system; we work together — that’s the only way to do it,” he said. “A lot of hospitals today want to open their own wound centers, but you have to be willing to standardize your care and hold yourself to a very high standard.” “At the start of my career, there were no wound centers,” he continued. “But wounds have always been ‘wounds’ — whether they’re due to diabetes, atherosclerosis, infection, trauma, war, whatever. The only thing different today is the way that we treat them. We understand more of the philosophy behind what heals wounds and how to better care for patients.” n

www.todayswoundclinic.com

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Elizabethtown,  KY  

 

  MANAGER,  WOUND  CARE/VASCULAR  CENTER   JOB  SUMMARY:  This  position  is  responsible  and   accountable  for  daily  operations  of  the  Wound  Care   and  Hyperbaric  Medicine  Center  and  the  Vascular   Center  to  include  fiscal  and  resource  management.   Develops/implements  processes  to  facilitate  timely   patient  throughput  for  Wound  Care  and  Vascular   Center  patients  and  maximize  utilization  of  rooms   and  time.  Schedules  patients  appropriately,  working   in  collaboration  with  referral  sources  to  maximize   efficiencies.  Collects  and  analyzes  data  to  ensure   targets  are  met.  Assists  in  marketing  the  (WCHMC)  to   physicians  and  the  community  within  the  service   area.  Maintains  open  communication  and   professional  relationships  with  members  of  the   medical  staff.     QUALIFICATIONS:  Current  unrestricted  license,  as  a   RN  in  Kentucky  required.  Successful  completion  of  an   approved/accredited  hyperbaric  medicine  training   course  within  60  days  of  hire  required.  Certification   as  a  Certified  Hyperbaric  Technician  (CHT)  or  Certified   Hyperbaric  Registered  Nurse  (CHRN)  within  18   months  of  hire  required.  Minimum  of  5  years  of   recent  clinical  experience,  two  years  of  wound   specialty  experience  required.  BLS  certification  within   90  days  of  hire  required.  BS  in  nursing  or  related  field   required.  Management/supervisory  experience   preferred.  Wound  Care  Certification  by  the  Wound   Ostomy  Continence  Nursing  Certification  Board   preferred.  Must  be  able  to  multitask.  Must  have   commitment  to  customer  service.  Must  be  familiar   with  CMS  and  Joint  Commission  regulations.   Please  visit  our  website  to  learn  more  about  our   wound  care  facility  at:   http://www.hmh.net/hmhwebsite/Location.aspx?P ageID=11.   Contact:   Lisa  Miller  or  Julianne  Hart,   Coordinators,  Recruitment/Retention   (270)  706-­‐1762  or  (270)  706-­‐1613   Email:    lmiller@hmh.net  or  jthart@hmh.net     Visit  us  on  the  web  at  www.hmh.net  to  apply  and   submit  resume.  

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Apligraf® Essential Prescribing Information Numbers in parentheses ( ) refer to sections in the main part of the product labeling. Device Description: Apligraf is supplied as a living, bi-layered skin substitute manufactured from cells processed under aseptic conditions using neonatal foreskin-derived keratinocytes and fibroblasts with bovine Type I collagen. (1) Intended Use/Indications: Apligraf is indicated for use with standard therapeutic compression in the treatment of uninfected partial and/or full-thickness skin loss ulcers due to venous insufficiency of greater than 1 month duration and which have not adequately responded to conventional ulcer therapy. (2) Apligraf is indicated for use with standard diabetic foot ulcer care for the treatment of full-thickness foot ulcers of neuropathic etiology of at least three weeks duration, which have not adequately responded to conventional ulcer therapy and extend through the dermis but without tendon, muscle, capsule or bone exposure. (2) Contraindications: Apligraf is contraindicated for use on clinically infected wounds and in patients with known allergies to bovine collagen or hypersensitivity to the components of the shipping medium. (3, 4, 5, 8) Warnings and Precautions: If the expiration date or product pH (6.8-7.7) is not within the acceptable range DO NOT OPEN AND DO NOT USE the product. A clinical determination of wound infection should be made based on all of the signs and symptoms of infection. (4, 5) Adverse Events: All reported adverse events, which occurred at an incidence of greater than 1% in the clinical studies are listed in Table 1, Table 2 and Table 3. These tables list adverse events both attributed and not attributed to treatment. (6) Maintaining Device Effectiveness: Apligraf has been processed under aseptic conditions and should be handled observing sterile technique. It should be kept in its tray on the medium in the sealed bag under controlled temperature 68°F-73°F (20°C-23°C) until ready for use. Apligraf should be placed on the wound bed within 15 minutes of opening the package. Handling before application to the wound site should be minimal. If there is any question that Apligraf may be contaminated or compromised, it should not be used. Apligraf should not be used beyond the listed expiration date. (9) Use in Specific Populations: The safety and effectiveness of Apligraf have not been established in pregnant women, acute wounds, burns and ulcers caused by pressure. Patient Counseling Information: VLU patients should be counseled regarding the importance of complying with compression therapy or other treatment, which may be prescribed in conjunction with Apligraf. DFU patients should be counseled that Apligraf is used in combination with good ulcer care including a non-weight bearing regimen and optimal metabolic control and nutrition. Once an ulcer has healed, ulcer prevention practices should be implemented including regular visits to appropriate medical providers. Treatment of Diabetes: Apligraf does not address the underlying pathophysiology of neuropathic diabetic foot ulcers. Management of the patient’s diabetes should be according to standard medical practice. How Supplied: Apligraf is supplied sealed in a heavy gauge polyethylene bag with a 10% CO2/air atmosphere and agarose nutrient medium. Each Apligraf is supplied ready for use and intended for application on a single patient. To maintain cell viability, Apligraf should be kept in the sealed bag at 68°F-73°F (20°C-23°C) until use. Apligraf is supplied as a circular disk approximately 75 mm in diameter and 0.75 mm thick. (8) Patent Number: 5,536,656 Manufactured and distributed by: Organogenesis Inc. Canton, MA 02021 REV: December 2010 300-111-8

Please see complete prescribing information at www.Apligraf.com © 2013 Organogenesis Inc. OI-A1112 All rights reserved. Printed in U.S.A. 03/13 Apligraf is a registered trademark of Novartis.

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Summary Physicians and NPPs who work in organized wound care programs receive referrals and refer patients for many other services and products that are separately billable to the Medicare program. Likewise, these same physicians and NPPs must write the orders for all services, procedures, and products that are provided/supplied to patients with chronic wounds. Therefore, these physicians and NPPs must ensure they are in the Medicare enrollment system. They must also verify that referring physicians have an NPI number and are listed in the Medicare enrollment system. This will ensure that Medicare claims will not be denied during the ordering/referring edits. Physicians and NPPs who are scheduled to provide direct supervision in HOPDs should have an NPI number and should be listed in the Medicare enrollment system. They must also be immediately available to assess new problems, to perform procedures, and to write orders before a care plan is changed and before a new/different service, procedure, or item is provided to the patient. n Kathleen Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at 561-964-2470 and kathleendschaum@bellsouth.net. 48

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Advertiser’s Index

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3M (Coban 2)............................................................... 33 ACell Inc. (MatriStem).................................................. 41 BSN Medical (Cutimed Sorbact gel)............................ 11 ConvaTec (Aquacel Foam).............................................. 5 Derma Sciences (TCC-EZ)...................................Cover 2 Healogics (Corporate).................................................. 19 Healthpoint Biotherapeutics (O-Day Global)................ 46 Innovative Therapies Inc. (Quantum NPWT)................ 27 KCI (Corporate)....................................................Cover 3 Matrix Health Services (Customized Wound Care Programs)........................... 45 Medela (Invia)................................................................. 3 MTI (Chairs).................................................................. 39 Net Health (WoundExpert)............................................ 15 Organogenesis (Apligraf)...............................Cover 4, 48 PathoGenius Laboratories (Corporate).................. 29, 31 Progressive Wound Care Technologies (Iodofoam)..... 35 Sechrist Industries (HBOT).................................... 24, 25 Shire Regenerative Medicine (Dermagraft)............ 21, 23 Spiracur (SNaP NPWT System)..................................... 9 www.todayswoundclinic.com

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April 2013