August/September 2005

Cover Story: Puzzling It Together

By Danielle Cohen

Casa Colina’s wound care program is state-of-the-art

Pressure mapping patient Rizalinda Ponis with Kathy San Martino, PT

"Initially, it was a physical therapy-based program. It was fairly limited and had one physical therapist and one physical therapy assistant, and no physicians on-site. That's evolved now into a physician-based wound care clinic, which is based on a nursing-physician model with a great deal of physical therapy involvement," says Kerry Gott, MD, medical director for the wound care and hyperbaric medicine program.

It was Gott, in fact, who was the driving force behind the change in wound care philosophy and delivery.

Before Casa Colina focused on physician-based wound care, Gott—who specializes in infectious diseases and wound care, and has been practicing as an infectious disease consultant for about 12 years—was frequently asked by other physicians to see patients who had wounds, with the assumption being that the wounds were infected. "They were not necessarily infected, in fact, but they were nonhealing wounds because of the underlying conditions that caused them to be wounds, rather than infections," Gott says.

In the process, Gott discovered that patients with chronic wounds were being referred to another local wound care program that had no physician involvement. "So the physicians in the community would refer the patients to a wound care program, but [one that was not] really involved in the wound care," he says. "The patient was getting a dressing change, and in that program, the PTs who were doing the wound change did a fine job as physical therapists, but their scope of practice was limited. There wasn't a physician who was actively evaluating the wound as a medical condition."

"They never really realized what was actually happening with the continuum of what that patient had," adds Patricia Reetz, PT, clinical coordinator of wound care at Casa Colina.

The two say limitations in a physician's level of expertise and time constraints endemic in modern medicine may be a hindrance in following a patient's wound care adequately. "Most physicians are not specifically trained in wound care … and may not be aware of current, advanced wound care practices," Gott says. "It's not a really attractive practice for a lot of people. We find that just means it's this wonderful opportunity for us to intervene where others haven't, can't, or don't have the experience. We can provide a service that, otherwise, the patient has not been offered. In this community, the thing that's different with Casa Colina is the physician involvement. It's important to have a physician who can evaluate the whole patient; evaluate their arterial disease, their cardiac disease, their diabetes, and so forth," he says.

The complexity of the problem makes this evaluation key in finding a solution. "It's like a puzzle—trying to put together all the different pieces that are causing this problem, and what we need to do to fix it," Reetz says.

FULLY STAFFED
The wound care center sits on the Casa Colina grounds, and has one full-time registered nurse, a physician's assistant, and medical assistants, and uses the services of the rehabilitation center's staff physical therapists, as needed. A wound specialist nurse also works at the clinic on a consultation basis, for inpatients and outpatients. The clinic sees about 15 to 20 patients per day.

For inpatients, the staff physical therapists still provide the majority of the wound care, with Gott as medical director. The inpatient wound care department has one physical therapist, one physical therapist's assistant, and another physical therapist to help with overflow evaluations and treatments. On average, the number of inpatients seen daily ranges between 12 and 18.

Casa Colina's staff physical therapists do get involved with outpatients at the wound care center, when needed, for pressure mapping, consultations, electrical stimulation, whirlpool, and ultrasound treatments.

While the personnel who provide the wound care on an inpatient or outpatient basis at Casa Colina may vary, the services offered do not.

TREATMENT STRATEGIES

Mary Bradshaw RN (left) treats Emma Blank in the wound care room.

Typically, Gott, as the physician and wound care consultant, coordinates the case with the primary physician and any general surgeon, plastic surgeon, vascular surgeon, podiatrist, or other physician who may already be working with the patient or who may be seeing the patient on referral by the wound care center. Contact with other physicians involved helps piece together the "puzzle" by providing background information as to how the patient might have developed their wound, including information about any previous surgeries or other procedures, stroke, spinal cord injury, or hospitalizations.

After that, the staff at the wound care center complete their own head-to-toe evaluation of the patient, looking at the wound and the factors that contribute to the delay in healing, Gott says. The evaluation incorporates a patient's cardiac, lung, and neurological function, as well as diabetes risk, mobility, nutrition, and medications, among other health factors that may be contributing to the problem.

Once a diagnosis—or diagnoses—is established, a treatment plan is drawn up. For outpatients, that treatment plan will also determine how frequently they need to return for wound care, and whether they need other diagnostic procedures such as radiological procedures to evaluate the vascular supply of the extremities, trans-

cutaneous oximetry to determine whether there is adequate oxygenation of the tissues, laser Doppler to determine skin perfusion, and any imaging procedures or blood tests. All of that information is conveyed to the referring physician.

Among the wound care services provided at Casa Colina are wound debridement; compression, for patients with venous-insufficiency ulcers; and offloading, for pressure ulcers and neuropathic ulcers. "Pressure ulcers can get very difficult sometimes. In the inpatient setting, we can observe when patients might have pressure on a wound, and we can influence what they do during most of their day; but in the outpatient setting, it's more difficult. It sometimes takes a little investigative work to figure out how and when they're getting pressure on this wound," Gott says.

The staff also uses specialty dressings and supplies to treat patients' wounds to promote moist wound healing and a proper balance of growth factors. Those include a variety of collagen products, topical growth factors, skin substitutes, and a topical enzymatic debridement agent that removes devitalized tissue.

STATE OF THE ART
Earlier this year, Casa Colina began initiating a hyperbaric therapy program in a new state-of-the-art facility created specifically for hyperbarics. The facility includes two hyperbaric chambers. Almost all of the patients who have used the facility—which is available for inpatients and outpatients—are wound patients.

"The basic principle is that if a wound is not healing because it's ischemic from lack of oxygen, then it may benefit from hyperbaric oxygen therapy," Gott says.

Patients, their families, and caregivers also receive training in wound care for follow-up. Some patients may also be referred to an on-site dietician for dietary education and support, when necessary. "A lot of patients who have chronic wounds are malnourished, and that's one reason why the wound doesn't heal," Gott says. "One of the things we also like to promote is [proper] nutrition. To that extent, the staff may prescribe appetite stimulants or anabolic steroids to improve a nitrogen imbalance."

While most wound care centers see a variety of patients, because of Casa Colina's focus as a rehabilitation hospital, most of the wound care patients that the staff see have sustained brain and/or spinal cord injuries, or have had a stroke.

Wound care services fit quite naturally into the overall rehabilitation program at Casa Colina. "A lot of times with the wounds, it limits patients' ability to move around or to do their activities of daily living (ADLs)," Reetz says, "so we also have the physical therapy component for mobility, the occupational therapy component for ADLs—dressing, training, grooming."

COORDINATION AND COMMUNICATION
All of the wound care services offered to patients at Casa Colina on an inpatient and outpatient basis require coordination and communication between the staff members.

Gott says the continuity of care from an inpatient to an outpatient basis and vice versa is a "big issue." To address that, Casa Colina has case managers who assist every inpatient and coordinate the discharge for a smooth transition to the outpatient clinic, home, or another facility where they will receive further wound care.

Almost all insurance plans are accepted at the wound care center. The center also serves as a treatment destination for patients from other facilities.

Gott says he hopes to expand the physician-based model to include involvement by other physicians in the surrounding community. Casa Colina recently underwent a series of construction projects, including the creation of an on-site imaging center and an ambulatory surgical center that will open soon, which should bring more physicians to the site, thereby allowing them to be more involved with their patients' wound care. "Right now, a lot of the surgeons are very busy at other facilities and they schedule surgeries at these facilities, and it's difficult for them to come here to see a patient," Gott says. "As we offer other services that the physicians can provide for their patients on campus, it'll be easier for them to be more involved with the wound care patients."

Danielle Cohen is associate editor of Rehab Management.

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