Establishing a wound care clinic can be a rewarding part of practice. These panelists draw on their wound care experience to discuss the essential clinical tools you need and also emphasize the importance of developing strong referral sources to help facilitate optimal outcomes for patients.
Q: What are the basic and bare minimum treatment modalities and tools you use daily in your wound care clinic?
A: All panelists cite the various vehicles of lidocaine. Both Stephanie Wu, DPM, and Caroline Fife, MD, use EMLA (lidocaine 2.5% and prilocaine 2.5%). Dr. Wu also uses topical lidocaine cream and will use lidocaine injections if necessary. Kazu Suzuki, DPM, uses topical lidocaine viscous gel as anesthesia before debriding a wound. He finds lidocaine to be “absolutely necessary” to decrease the pain and discomfort that can occur with debridement.
Dr. Wu’s debridement tools include a scalpel and curettes of varying sizes. She says the curette is one of her favorite debridement tools. Likewise, Dr. Suzuki utilizes disposable scalpels #10 and #15 as well as a 4 mm disposable curette for debridement. He notes that nail clippers, tissue nippers and bone rongeurs can be helpful. Dr. Fife cites the efficacy of ultrasonic debridement and adds that it is painless. She also uses maggot debridement.
Since founding a wound clinic in 1990, Dr. Fife has found in her experience that factors like adequate compression, revascularization and offloading are usually more critical than dressing selection.
Dr. Suzuki uses a lot of foam dressings as well as composite foam dressings that allow patients with wounds to shower. He likes the silicone-based adhesive in wound dressings such as Mepilex (Molnlycke), which are less painful to remove. Dr. Suzuki also uses Ace wraps, cohesive wraps such as Coban and Coflex, and cotton cast padding to secure the dressings and control edema.
Dr. Wu also notes that a myriad of wound dressings are available.
“Although one should tailor dressings to the individual patient’s needs, the basic rule of thumb is ‘if a wound is wet, dry it and if a wound is dry, wet it,’” points out Dr. Wu.
Dr. Wu also emphasizes mitigating pressure for plantar diabetic foot ulcers and offering appropriate compression for those with venous insufficiency ulcers.
Q: Which diagnostic tools do you use?
A: For the past 20 years, Dr. Fife has used transcutaneous oximetry but in the past three years, she has started using skin perfusion pressure. Drs. Wu and Suzuki also cite the measurement of skin perfusion pressure with Dr. Suzuki using Sensilase (Vasamed) for the more precise diagnosis and documentation of ischemia. Dr. Wu also says there are precise machines to help measure skin perfusion pressure and oxyhemoglobin and deoxyhemoglobin values.
As Dr. Fife notes, the key is to perform non-invasive vascular screening for all patients with lower extremity ulcerations so one does not miss arterial disease in at-risk patients. However, since there is no consensus as to the overall best non-invasive screening method, Dr. Fife advises picking a screening method that one feels most comfortable using. In choosing a screening method, key considerations include training of staff, cost of equipment and one’s comfort in interpreting the results.
Emphasizing the importance of having a good set of vascular diagnostic tools, Drs. Wu and Suzuki note that, at the minimum, one should have a Doppler. One can use the Doppler to identify ischemic patients and determine who needs a referral to a vascular specialist.
Semmes Weinstein monofilaments and VPT meters can help diagnose neuropathy, according to Dr. Wu. She adds that dermal thermometers are helpful in diagnosing and treating Charcot. Dr. Wu says wound culture tubes are also a must to help identify infectious organisms. She also keeps biopsy kits on hand. When an adequately vascularized, non-infected, well offloaded wound does not respond to treatment, Dr. Wu encourages clinicians to obtain a biopsy of the wound.
Q: Do you find any other equipment and modalities to be valuable?
A: Dr. Suzuki cites the efficacy of hyperbaric oxygen therapy (HBO). He says “having a HBO clinic within or near your clinic is enormously helpful, especially when limbs and toes are critically infected or ischemic (i.e., severe diabetic foot infections and traumatic amputations).” Dr. Fife also uses HBO therapy.
Negative pressure wound therapy devices such as VAC therapy (KCI) are essential for deep, gaping wounds and Dr. Suzuki calls it a gold standard for most pressure ulcers.
He also uses various types of skin substitutes such as Oasis (Healthpoint), Apligraf (Organogenesis), Dermagraft (Advanced Biohealing), and Alloderm (LifeCell). He says those products are convenient substitutes for split-thickness skin grafting in many of his older patients with poor skin integrity.
A few months ago, Dr. Suzuki started using Qoustic (Arobella Medical), an ultrasound-assisted wound debriding device. He says the product is “much better” than a scalpel for wound debridement.
Increasing rates of obesity can be a concern for wound clinics.
“While we often spend a lot of time focusing on equipment like HBO chambers and debridement devices, we have had to completely reengineer our clinic to accommodate the increasing size and girth of our patients,” notes Dr. Fife. “In the almost 20 years we have been open, we have seen a steady increase in the BMI of our patients.”
Due to the increase of larger patients, her clinic has had to obtain wider waiting room chairs, hydraulic exam tables, a Hoyer lift and a $10,000 electric wheelchair that can move patients weighing up to 800 pounds. Dr. Fife’s wound care facility also has an open “bay” area for examining bed bound patients with pressure sores. She emphasizes that wound centers need to be designed with very large exam rooms and wide hallways in order to accommodate large patients. These patients may transport themselves in their own electronic devices and they often come with family members or caregivers.
Dr. Fife says the most important “equipment” in her clinic is what it uses to document and bill services. Her company, Intellicure, was designed to manage wound center data such as measurements, photos and dressings, as well as calculating the facility and the physician level of service so one is always in compliance with billing rules. This year, she says Intellicure will transmit data to CMS as part of the pay for performance quality reporting initiative.
Q: Which medical specialty do you find essential when it comes to referring patients to ensure optimal care?
A: Dr. Suzuki advocates establishing a good working relationship with local vascular specialists, such as vascular surgeons, interventional cardiologists and interventional radiologists. He says this is “absolutely essential if you are committed to state-of-art wound care.”
Dr. Wu agrees that a good vascular surgeon can improve perfusion for ischemic wounds and treat the underlying venous disease. She often consults with infectious disease specialists and internists for co-management of the patient. Dr. Suzuki says infectious disease doctors have been a great source of collaboration and referrals for his clinics. Dr. Wu concurs.
Dr. Fife’s facility runs a lymphedema clinic and its staff, which is separate from the wound clinic staff, is trained in manual lymphatic drainage techniques and lymphedema bandaging. She says the lymphedema clinic is helpful for patients with secondary lymphedema.
Dr. Fife praises the consulting invasive cardiologists and the endovascular surgeons who do the majority of her facility’s revascularizations. Over a decade ago, she started to recommend endovascular procedures for her wound center patients since the risks of vascular surgery were so high in those patients.
Dr. Wu says a good pathologist can help confirm osteomyelitis and ulcers secondary to other possible underlying causes such as pyoderma gangrenosum and vasculitis. A good pedorthist will work with her patients on appropriate shoegear to alleviate pressure and help prevent ulcer recurrence. Dr. Wu also works with rheumatologists and diabetologists when necessary.
One day a month, a dermatologist visits Dr. Fife’s clinic to assist in the care of patients with vasculitis or wounds of unusual etiologies. She frequently performs biopsies for quantitative cultures and pathology.
However, Dr. Fife notes that she may also ask dermatology to perform biopsies and subsequently assist in managing the patients afterward. Dr. Fife points out that one of the best dermatopathologists in the country reviews her clinic’s specimens and he can also examine photos of the wound in context with the biopsy specimen.
Dr. Fife’s facility also has a monthly consult from a plastic surgeon, who sees all the patients who might be ready for flaps or grafts. She and the plastic surgeon see the patients together so she can present their cases. Often the patients are getting negative pressure wound therapy and she and the plastic surgeon will decide whether they have reached maximum benefit from that modality, and whether the patients are good surgical candidates since many have multiple comorbid conditions.
Q: Do you have any words of advice for those new to wound care practice?
A: Dr. Fife emphasizes teamwork. For example, she greatly relies on the judgment of her nurses and one also needs a good team of medical specialists including dermatologists, vascular surgeons, plastic surgeons, general surgeons and infectious disease specialists. Dr. Fife says it is important to work well with referring physicians to manage patients' underlying medical problems, and emphasizes regular communication with referring physicians.
While wound care can be rewarding, Dr. Wu notes patients are often depressed and frustrated with their condition. This can make communication difficult.
Dr. Wu also notes that the high-risk wound care patient population is often plagued with comorbidities and is prone to wound infections.
“Be patient and alert,” says Dr. Wu. “Wounds do not often respond to therapy despite our efforts so patience is a must. One should be alert to ensure the alleviation of other factors that may impede proper healing.”
Dr. Suzuki also emphasizes patience. He notes that some patients with wounds may not follow medical advice on matters like quitting smoking. Patients may also have comorbidities that prevent them from improving. He has been treating some wound care patients for two years with palliative care but they have avoided leg amputation, and they are happy about that.
Dr. Fife counsels those who are just getting started in wound care not to let new modalities obscure the fundamentals.
“I do not jump on every new thing that comes out. I am happy to try new products but they never substitute for good basic care,” explains Dr. Fife. “Sometimes we have to remind ourselves to stick to the basics. Learn the basics very well and then build on that foundation little by little.”
Dr. Fife is an Associate Professor in the Department of Anesthesiology at the University of Texas Health Science Center in Houston. She is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine.
Dr. Wu is an Assistant Professor in the Department of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. She is the Director for Educational Affairs and Outreach at the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.
Dr. Suzuki is the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.