What You Should Know About Starting A Wound Care Clinic
- Volume 21 - Issue 11 - November 2008
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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.