June/July 2012 by HMP Communications, LLC

, LLC

™

Today’s

Contemporary Approaches to Wound Clinic Management

Diabetes

&Wounds

Focus On: Foot Neuropathy, Disease Control Also in This Issue: Dangers of Patient Referrals Business Briefs: Medicare Summary Notices

June/July 2012 www.todayswoundclinic.com

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SAWC FALL

THE SYMPOSIUM ON ADVANCED WOUND CARE

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Today’s

Volume 6, Number 5, June/July 2012 • www.todayswoundclinic.com

Table of Contents • Feature Articles 8

Addressing Diabetes Control: What Clinicians Must Know

Lower Extremity Ulcer Management: Practical Concepts

Diabetes mellitus can have the most profound effects on wounds and wound healing. If patients are going to achieve optimal outcomes, clinicians have to fully understand the disease process and motivate patients to self-manage as part of the care plan.

s the number of people living with diabetes climbs in the US, A so too does the rate at which patients experience lower extremity ulcers. Even as advances in healthcare are continuously made, these wounds remain difficult to manage.This guide discusses evaluation, offloading, and surgical considerations related to these ulcers.

Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA & Jason Hardage, PT, DPT, DScPT, GCS, NCS, CEEAA

Steven J. Lieberson, DPM

22 Yes % 46.5 No % 53.5

Treating Painful Neuropathy Associated With Diabetes

For those patients who live with diabetes, incidence and severity of neuropathy only increase with time. And while trying to change a patient’s unhealthy habits is one of the most frustrating challenges for clinicians, reduce pain remains one of patients’ greatest demands. Suggested treatment measures clinicians should know can be useful in alleviating pain and improving quality of life.

Richard Kobylar, DPM

B 66.4 %

A 33.6

Navigating The Inherient Dangers of Patient Referrals

Available lines of communication continue to expand as use of email and mobile phones by healthcare providers and patients increases. But traditional communication appears to be lagging, especially when it comes to the referral process. If you struggle to effectively communicate with providers and patients when making referrals, you’re not alone. See results from a TWC survey that prove as much, and get some insight on how to “cure” a communication letdown.

Desmond Bell, DPM, CWS & Moira Hayes, MHA, RRT, CHT 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. ®

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

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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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Editorial Staff

Today’s

Volume 6, Number 5, June/July 2012 • www.todayswoundclinic.com

Web Editor Samantha Alleman salleman@hmpcommunications.com

Departments

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

Editor’s Note Caroline Fife, MD, FAAFP, CWS

VP/Group publisher Jeremy Bowden jbowden@hmpcommunications.com

6 Business Briefs Are You Prepared to Answer Questions About New Medicare Summary Notices? Kathleen D. Schaum, MS

Industry Insider An inside look at Net Health Systems Inc.

Associate Publisher Kristen J. Membrino kmembrino@hmpcommunications.com SALES ASSOCIATE Sydney Slater sslater@hmpcommunications.com Classified advertising Associate Christine Gabel cgabel@hmpcommunications.com

HMP Communications, LLC

29 TWC News Update Study links diabetes drug, cancer;

PRESIDENT BIll Norton

PA hospitals add wound centers

Founding Editorial Board Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS Managing Editor Joe Darrah jdarrah@hmpcommunications.com

Table of Contents 4

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

Controller Meredith Cymbor-Jones

Advertiser Index

Vice President, Special Projects Jeff Hall Marketing Manager Stephanie Manzo

TWC Online

Creative Director Vic Geanopulos vgeanopulos@hmpcommunications.com

www.todayswoundclinic.com Exclusive: Meet Our Editorial Board Today’s Wound Clinic has welcomed new members to its editorial board. Get to know each clinician, their background, and their expertise. Exclusive: Patient Referral Survey Results Thanks to all who participated in our most recently emailed survey: “Patient Referrals in Wound Care.” We’ve compiled all the results, and they can only be found online.

Art Director Bernadette Zeminski bzeminski@hmpcommunications.com Senior Production Manager Andrea Steiger asteiger@hmpcommunications.com Production/ Circulation Director Kathy Murphy kmurphy@hmpcommunications.com Audience Development Manager Bill Malriat MEETING PLANNER Tracy Blithe, CMP

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

MEETING PLANNER Mary Beth Kurimay

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

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 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 Sr. Manager, IT Ken Roberts

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Invia Liberty ®

SIMPLIFYING NEGATIVE PRESSURE WOUND THERAPY The innovative design of the Medela Invia Liberty NPWT System delivers user friendly functionality with a simple set-up and easy operation for the clinician and patient. The Invia Liberty NPWT System can be used in a hospital, home or long term care setting, easing transitions and avoiding the need for clinicians and patients to learn a new pump. Medela provides foam and gauze wound dressing kits, along with multiple drain options to help you fully manage the clinical needs of your patients.

Invia ® Liberty Negative Pressure Wound Therapy

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Precious life – Progressive care 1547741 A 0112 © 2012 Federal law restricts this device to sale or rental by or on the order of a physician. Avance Dressing Kits distributed by Medela, Inc. Medela and Invia are registered trademarks of Medela Holding AG. Liberty is a trademark of Medela, Inc. Avance is a registered trademark of Molnlycke. Medela, Inc. 1101 Corporate Drive, McHenry, IL 60050, USA Phone: 1 877 735 1626 Fax: 1 815 307 8942 suction@medela.com www.medelasuction.com

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introduction

Today’s

patient of mine developed a popular prescription drug that’s frequently advertised on TV. A brilliant physician who presented with plantar foot ulcers on both feet the first time we met, he claimed to have acquired the ulcers from walking on the hot, sandy beaches of his second home in the Bahamas. But he was baffled when I inquired about the etiology of his obvious peripheral neuropathy. “I just have a high pain tolerance,” he mused. I suggested undiagnosed diabetes, with other possibilities including B12 deficiency or too many martini lunches. Despite his brilCaroline Fife liance, it took a lot of convincing for him to agree to Co-Editor of TWC total contact casting and checking his hemoglobin A1c. He now self-treats the diabetes he previously did not want to admit he lived with. His foot ulcers have healed with aggressive offloading.

Editorial Board

FOCUS ON FEET

Andrew J. Applewhite, MD, CWS, UHM

Given how difficult it was for me to “persuade” a fellow physician to get tested for diabetes, how can we expect to succeed with the average patient? We hope to help answer that question in this issue of Today’s Wound Clinic. In “Addressing Diabetes Control: What Clinicians Must Know” on page 8, Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA, and Jason Hardage, PT, DPT, DScPT, GCS, NCS, CEEAA, address the impact of diabetes on overall health, the impact of hyperglycemia on wound healing, and current treatment interventions. My patient was able to walk barefoot on hot sand without realizing the trauma to his feet because he did not have the “gift of pain,” a term coined by the late Paul Brand while he worked with leprosy patients in India. As an indicator that lets us know something is wrong, the value of pain becomes clearest in its absence. The great irony of peripheral neuropathy is that patients lose protective sensation even as they develop neuropathic pain. Podiatrist Richard Kobylar, DPM, reviews the pathophysiology of peripheral neuropathy and discusses the latest treatment modalities in “Treating Painful Neuropathy Associated With Diabetes” on page 17. Podiatrist Steven J. Lieberson, DPM, discusses what it takes to offload an ulcer to achieve healing and the options for long-term offloading of the diabetic foot in “Lower Extremity Ulcer Management: Practical Concepts” on page 14.

CONSTRUCTIVE COLLABORATION There are many wonderful clinicians with whom I collaborate on a regular basis, but it becomes a challenge to keep lines of communication regarding patients and their care open the more people become involved in that care. Recently, I played “telephone tag” with a vascular surgeon, a hematologist, a rheumatologist, a cardiologist, a podiatrist, and an orthopedic surgeon over the course of one day. In our special feature article “Navigating the Inherient Dangers of Patient Referrals” on page 22, fellow TWC editorial board members Desmond Bell, DPM, CWS, and Moira Hayes, MHA, RRT, CHT, share personal experiences regarding the challenges they face when referring patients to other providers. We also provide the results of a survey that saw more than 500 TWC readers and SAWC attendees participate. Additionally, Kathleen D. Schaum, MS, addresses new Medicare Summary Notices in her “Business Briefs” column beginning on page 6. I easily realize how each of these articles is pertinent to patients I’ve seen just today. This further strengthens why we aptly call this journal Today’s Wound Clinic! Caroline Fife, co-editor of TWC, chief medical officer at Intellicure Inc., cfife@intellicure.com

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

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

83 General Warren Boulevard, Suite 100, Malvern, PA 19355 © 2012, 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.

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businessbriefs Are You Prepared to Answer Questions About New Medicare Summary Notices? 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. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

ound care providers and suppliers are accustomed to two things: 1) submitting claims to Medicare for services and products provided to beneficiaries and 2) reviewing Medicare’s Explanation of Medical Benefits to learn what Medicare paid and what they must charge to the patient or to the patient’s supplemental insurance. However, providers and suppliers are not always comfortable when Medicare patients who live with chronic wounds confront them or their staff with a bill they’ve received. Some of the most common questions that Medicare patients ask are:“Why does ‘this’ cost so much?” “Why did you bill for something that I did not receive?” and “Why didn’t Medicare pay for ‘this’ or ‘that’?” In some cases, these patients may be referring to the bill you sent them.

In other cases, they may be referring to their Medicare Summary Notice (MSN), the statement that informs Medicare beneficiaries about their claims for Medicare services and benefits. All wound care providers and their staff should always: 1) ascertain whether questions pertain to the bill and/or the MSN, and 2) take the time to assist their patients with billing questions. If the patient was cared for by a physician, podiatrist, or non-physician practitioner in a hospitalbased outpatient wound care department (HOPD), the patient will receive two bills: one from the wound care professional and one from the HOPD. In that circumstance, you must clarify whether the patient’s question is regarding the professional bill or the HOPD bill. Following is some basic information and instruction that you and your staff should provide to Medicare patients: • A bill itemizes the charge for each medical service, procedure, separately payable drug/biologic, separately payable equipment, and separately payable supply received on a given date of service. Each year Medicare determines the exact amount of money allowed for each service, procedure, and separately payable product. The patient is responsible

for paying coinsurance based on the established Medicare allowable rates, not based on the actual charge on the bill. • The MSN itemizes all services, procedures, and separately payable products that wound care providers and suppliers billed to Medicare in the past 3 months. It shows the portion of the Medicare allowable rate that Medicare paid to the wound care provider/supplier and the coinsurance you may owe, if you do not have supplemental insurance. Medicare mails MSNs every 3 months if you received a Medicare-covered service in that time period. You do not have to wait until you receive the MSN to view claims submitted by a wound care provider/supplier. Medicare claims can be tracked and electronic MSNs are available online at www.mymedicare.gov, Medicare’s secure online service for personalized information regarding benefits and services. Claims are generally available within 24 hours of Medicare receiving and processing the claims. • Keep receipts and bills, and compare them to the MSN. • If a bill is paid prior to receiving the MSN, compare the MSN with the bill to ensure the correct amount has been paid. • If you have other insurance, check to see if it covers anything that Medicare didn’t. • If an item or service is denied, call your wound care provider/supplier to confirm the correct information has been submitted to Medicare and to the supplemental insurer. If not,

Table 1. How to Check This Notice

Do you recognize the name of each doctor or provider? Check the dates. Did you have an appointment that day? Did you get the services listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.

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businessbriefs the wound provider/supplier may resubmit the Medicare claim and/or supplemental insurance claim. • If there’s a disagreement with any decision made by Medicare or supplemental insurer, file an appeal. Now, if you’re thinking, “I don’t have time to discuss the patient’s bill and/or the MSN with everyone,” I’d challenge that thought. No provider should miss this opportunity to discuss Medicare billing and payment questions with patients.Following is the rationale for that mindset: On March 7, 2012, the Centers for Medicare & Medicaid Services (CMS) announced the redesign of the MSN, which generally describes what Medicare has or has not covered and provides information about the beneficiary’s payment responsibilities. It also describes the process for initiating an administrative appeal when a beneficiary questions a denial of coverage.This MSN redesign is part of a new initiative, “Your Medicare Information: Clearer, Simpler, At Your Fingertips.” The goal of this initiative is to make Medicare information more understandable and more accessible.The new MSN became available shortly after the CMS announcement to Medicare beneficiaries. Early in 2013, paper copies of the redesigned MSN will start to replace the current version that is mailed to beneficiaries on a quarterly basis. The redesigned MSN includes several features that are new to Medicare beneficiaries, including: • A clear notice of how beneficiaries should check the MSN for important facts (see Table 1) and potential fraud (see Table 2); • An easy-to-understand snapshot of the beneficiary’s deductible status; • A list of providers the beneficiary saw; • A clear answer to whether the beneficiary’s claims for Medicare services were approved; • Clearer language overall, including consumer-friendly descriptions for medical procedures; • Definitions of all terms used in the MSN (see Table 3); • Larger fonts throughout the MSN

Table 2. How to Report Fraud

If you think a provider or business is involved in fraud, call 800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services or billing you for Medicare services you didn’t get. If it’s determined that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, taxpayers saved $4 billion – the largest sum ever recorded in a single year – thanks in large part to people who came forward and reported suspicious activity.

Table 3. Your Claims for Part B (Medical Insurance)

Part B Medical Insurance helps pay for doctors’ services, diagnostic tests, ambulance services, and other healthcare services. Definitions Service Approved?

This column tells you if Medicare covered this service.

Amount Provider Charged:

This is your provider’s fee for this service.

Medicare Approved Amount:

This is the amount a provider can be paid for a Medicare service. It may be less than the actual amount the provider charged. Your provider has agreed to accept this amount as full payment for covered services. Medicare usually pays 80% of the Medicare-approved amount.

Amount Medicare Paid:

This is the amount Medicare paid your provider. This is usually 80% of the Medicare-approved amount.

Maximum You May Be Billed:

This is the total amount the provider is allowed to bill you, and can include a deductible coinsurance and other charges not covered. If you have Medicare Supplement Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

to make it more reader-friendly; and • Information on preventive services available to Medicare beneficiaries. To view the document and compare it to the former MSN, CMS has posted a side-by-side comparison online at www. cms.gov/apps/files/msn_changes.pdf. Medicare beneficiaries will now have a better description of the services and products they’ve received, who provided them, the Medicare allowable, their deductible status, their coinsurance responsibility, their right to appeal (including clear appeal instructions), and straightforward instructions for reporting suspected Medicare fraud. Beneficiaries will also be

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empowered to challenge their provider and/or supplier charges and to report suspected Medicare fraud (with the possibility of receiving a reward). Therefore, wound care providers and staff should take the time to understand the redesigned MSN and to willingly discuss both their bills and the correlating MSN with their Medicare beneficiaries. n Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. Ms.Schaum can be reached for questions and consultations by calling 561-964-2470 or by emailing kathleendschaum@bellsouth.net.

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Addressing Diabetes Control:

What Clinicians Must Know Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA & Jason Hardage, PT, DPT, DScPT, GCS, NCS, CEEAA

hile many comorbidities have the potential to impact wound healing, this is especially true of diabetes mellitus (DM), a common disease among patients living with wounds. The impairments related to the disease state of DM affect all wound etiologies and impair all phases of healing. Healthcare professionals must understand the DM disease process and its implications in order to promote optimal wound healing.While another provider oversees the medical management and coordinates the team care of DM, the wound care clinician should ensure adequate control of the disease is met. This article provides an overview of DM epidemiology, its effects on healing, the clinical challenges it poses, and considerations for wound care clinicians. (For information on pathophysiology, consult other sources, including standards of care by the American Diabetes Association.1)

Epidemiology & Implications

DM has been at epidemic levels worldwide for some time,2,3 having farreaching implications for public health and healthcare systems. The statistics are, in all probability, underreported4 (see Table 1). Diabetes has a profound impact on health, comprising a leading cause of such secondary complications as heart disease, kidney disease, retinopathy, neuropathy, and lower-limb amputation. Making matters worse, younger people are acquiring type 2 DM (T2DM) as early as age 10.5 Accordingly, providers are seeing younger people experiencing DM-related complications, includ-

ing wound healing issues. Current evidence demonstrates that DM inhibits all phases of wound healing via impaired function of the primary cells responsible for wound repair (ie, neutrophils, macrophages, and fibroblasts), frequently resulting in slow-healing or chronic, nonhealing wounds. In addition, there is decreased efficacy of cytokines and growth factors in people living with DM and accompanying hyperglycemia. The accumulation of advanced glycosolated end products, nitric oxide dysfunction, decreased insulin availability or increased insulin resistance, and altered homocysteine levels also contribute to the complex host of impairments that affect healing. Microvascular and macrovascular, neuropathic, immune function, biochemical, and hormonal abnormalities contribute to the altered tissue-repair processes in people with DM and hyperglycemia.6 One example of a DMmediated impairment in wound healing is susceptibility to infection. Under normal conditions, during the coagulation phase, there is immediate fibrin plug formation as platelets aggregate at the wound site. The platelets release various growth factors and cytokines, which cause recruitment of inflammatory cells. However, in a hyperglycemic environment, there is a delay in fibrin plug formation, leaving the wound open to contaminants, in addition to a delay (and decrease) in the release of growth factors and cytokines, causing impaired recruitment of inflammatory cells. With this delay, the individual is prone to infection. In fact, people living with DM

8 June/July 2012 Todayâ&#x20AC;&#x2122;s Wound ClinicÂŽ

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have more frequent infections than those without DM.6 Research in human and animal models has identified many of the changes that contribute to faulty wound healing at the molecular level. Additionally, focused research on the causes of and interventions for diabetic neuropathic foot wounds remains ongoing.7 While the underlying mechanisms of the effects of DM on healing have been extensively investigated over the past few decades, more work is needed to fully elucidate the complex, multifaceted pathophysiologic relationship between DM and defective healing.6,8

Medical Management & Team Care

Diabetes management requires a team approach to patient-centered care, with the patient being an integral member of the team. While the medical team leader is the physician or advanced-practice nurse who uses input, education services, and treatment recommendations from other healthcare providers, daily disease management is provided by the patient (or caregiver when impairments prohibit self-management).8 Following are the basic elements of a well-rounded DM management program: â&#x20AC;˘ Diabetes Self-Management Education/Training (DSME/T): Defined by the American Association of Diabetes Educators as a collaborative process through which people living with or at risk of DM gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and

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diabetes&wounds Table 1. Diabetes in the US4 • 25.8 million: Total population living with DM: o 1.29 million: Population with T1DM diagnosed o 17.5 million: Population with T2DM diagnosed o 7 million: Estimated population with undiagnosed T2DM • 79 million: Estimated population with prediabetes Key: DM=diabetes mellitus; T1DM=type 1 DM; T2DM=type 2 DM Table 2. Diabetes Education Content Areas10 • Describing DM disease process and treatment options • Incorporating nutritional management into lifestyle • Incorporating PA into lifestyle • Using medication(s) safely and for maximum therapeutic effectiveness • Monitoring BG and other parameters, and interpreting and using the results for self-management decision-making • Preventing, detecting, and treating acute complications • Preventing, detecting, and treating chronic complications • Developing personal strategies to address psychosocial issues and concerns Key: DM=diabetes mellitus; PA=physical activity; BG=blood glucose

its related conditions (see Table 2).10 Aims to achieve optimal health status, better quality of life, and reduced healthcare costs by incorporating the needs, goals, and life experiences of the patient while evidence-based standards of care are met. Informed decision-making and problem-solving are crucial.10 Standards of care require patients receive self-management education upon diagnosis.1,15 • Medical Nutrition Therapy (MNT): The preferred term when referring to nutrition interventions, as opposed to “diabetic diet,” “diet therapy,” or “dietary management.” A comprehensive approach

to eating that the patient learns to employ for optimal control of blood glucose (BG), with weight control a secondary outcome. Goal is “to assist and facilitate individual lifestyle and behavior changes that will lead to improved metabolic control.”11 • Physical Activity (PA): Defined as bodily movement produced by the contraction of skeletal muscles that substantially increases energy expenditure, whereas exercise is recognized as a subset conducted with the intention of developing physical fitness (ie, cardiovascular, strength, and flexibility training).12

A powerful modality that must be coordinated with the medication and nutrition regime. When added to insulin or oral agents, can cause uncomfortable and/or life-threatening hypoglycemic events. Associated complications (eg, diabetic retinopathy, diabetic neuropathy, or diabetic nephropathy) may necessitate certain precautions and contraindications for PA. Where there are musculoskeletal, neuromuscular, or cardiovascular impairments, a referral to a physical therapist may be appropriate.9 •P harmacological Management: The drug armamentarium for gly-

Clinical Consideration:

People with blood glucose (BG) > 180 mg/dL rarely achieve optimal healing. Neutrophilic function is impaired at BG > 180 mg/dL, while fibroblast and collagen synthesis are impaired at BG > 200 mg/dL.9 10

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Harnessing Technology For Healthcare™

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diabetes&wounds Patient Scenario: Patient with comorbidity of diabetes mellitus (DM) presents with a wound with signs and symptoms of infection. Blood glucose (BG) level is 345 mg/dL. Which came first: chronic hyperglycemia, which increases susceptibility to infection, or the infection, which caused BG levels to increase? To help make this determination, the clinician can compare the results of the capillary BG test to a current A1c test (see Figure 1).1 If the A1c value is high, BG has been out of control long-term; DM management strategies are paramount. If the A1c value shows adequate control, DM has been well managed; infection has caused elevated BG levels. At this point, the patient may require the addition of insulin to medication regime (at least temporarily) to help control infection-induced elevated BG. The wound care clinician can make this recommendation, thus using objective glycemic tests to enhance healing opportunities, remembering that DM is ever present and must be managed at all times.

cemic control for patients living with DM is fairly large and growing as impairments related to DM are better understood. Different drugs and combination therapies address different pathophysiological mechanisms. The management of type 1 DM (T1DM) and T2DM is different, as these are different diseases with the similar outcome of hyperglycemia.8 Medications comprise oral classes and injectables, including insulin. • Monitoring of Glycemic Status: As performed by patients and healthcare providers, a cornerstone of DM care. Results are used to assess efficacy of overall management, to guide adjustments to MNT and exercise, to determine effectiveness of the medical plan regarding medications, and to determine how illness is affecting BG status — all for the purpose of achieving the best possible BG control.13,14 The two techniques most frequently used to assess glycemic control and the effectiveness of various interventions are patient self-monitoring of BG

(which may be performed when needed by a healthcare provider, family member, or other caregiver for those who are homebound or in nursing facilities) and a laboratory test, the glycosylated hemoglobin or hemoglobin A1c (A1c) test, to measure average glycemia over the preceding 2-3 months to determine overall efficacy of the DM plan of care.9

Challenges Faced by Patients

There are many challenges in providing care for this patient population. Notable issues include those related to: 1) E ducation. Patients require education for self-management of DM and wound care. Many people with chronic wounds and DM do not have all of the information they need to adequately manage their disease, especially in the presence of a chronic wound that places more stress on them both psychologically and physiologically. The standard of care is referral to a comprehensive DSME/T program;1,15 however, many patients do not have ac-

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cess to an education center, nor do their primary care providers have the time or resources to adequately educate them regarding their DM management. Such individuals thus present to the wound clinic with a critical deficiency in their ability to manage their disease. This deficiency is often a contributing factor to the development of the wound and becomes a hindrance to healing. 2) Depression and burnout. Many people living with DM experience depression.16 With depression, DM selfmanagement can become severely compromised, depending on the individual’s coping abilities, presenting more challenges for healing. Diabetes conveys psychological, social, and financial burdens on the affected individual. The wound brings additional psychological, social, and financial burdens.8 Burnout (ie, a sense of emotional exhaustion, depersonalization, reduced personal accomplishments) is a potential consequence of DM. Wound care providers can also become burned out from patient care, especially when there’s a perception that the patient is not self-managing the DM or the wound, thereby “sabotaging” the care plan.The psychosocial impact of DM is life-altering, especially with the addition of chronic complications that frequently accompany DM, including wounds, which patients and caregivers may consider unsightly and too odiferous. There are no easy answers or rote formulas for these challenges. Providers must simply give the most comprehensive support within their means.8 3) Adherence. Patient adherence to the overall disease management plan is critical. However, before labeling someone as “non-compliant” or “non-adherent,” the wound care clinician should assess whether the patient has a functional DM management plan individualized to his or her needs and whether the patient knows how to self-manage the DM,

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diabetes&wounds Figure 1. Correlation of A1c Values with Average Glucose1

126

154

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183

212

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11%

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providing an appropriate referral as needed. Doing so promotes an environment in which the wound can close and go on to full maturation and healing. Many people living with T2DM do not receive adequate education for successful self-management, yet they are blamed for being non-adherent. Provide a referral for DSME/T if necessary and where possible, then provide ongoing monitoring of the person’s success with DM self-management as the wound is managed in the clinic. Provide encouragement, with empathy and understanding of the difficult task these patients face. Describe DM selfmanagement as a lifelong process, and help the patient understand the benefits, including improved wound healing, that make the hard work worthwhile. This approach promotes rapport and open communication.

Wound Care Clinician’s Role

The initial examination of the patient and wound should include a basic assessment of the DM management plan. The following questions are some intake components to consider:

• Have you had a series of DM selfmanagement classes? How long ago? (If not, then a referral is indicated.) • What medications do you take for DM? List the name and dose of each medication. Note: Sometimes a person with T2DM is further along in the disease process of beta-cell failure than when he or she first started treatment for DM. Because T2DM is progressive, lifestyle management or oral medications initially prescribed may no longer provide the control they once did. The wound care clinician may recognize or suspect the medications are not providing needed coverage. Thus, a referral is necessary for evaluation of the need to add another oral medication or start insulin, especially if the patient is not having the DM regularly evaluated by his or her primary care practitioner. • Do you take your DM medications regularly without fail? If not, how often do you take them? Note: Ensure that this question is not judgmental; just try to get the facts. People who are on fixed or low in-

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Mean Plasma Glucose (mg/dL)

comes may take their medications sporadically to try to make them last longer. Older people may become confused about medication regimes or embarrassed to admit they need help. The wound care clinician may be the first to recognize mental status changes or signs of abuse and/ or neglect that impact self-management. Adherence or non-adherence is often a complex issue reflecting other, underlying areas of concern. Other areas for targeted assessment of the patient’s DM self-management include self-monitoring of BG, nutrition and hydration, and PA. Clinicians should keep the DM-related assessment manageable and remember their role in assessing the success of the patient’s self-management is paramount for optimal wound healing outcomes. n Pamela Scarborough is director of public policy and education for American Medical Technologies, Irvine, CA. Jason Hardage is assistant professor in the department of physical therapy at Texas State University-San Marcos. References for this article can be accessed online at www.todayswoundclinic.com or by emailing jdarrah@hmpcommunications.com.

Today’s Wound Clinic®

June/July 2012

6/7/12 5:04 PM

Lower Extremity Ulcer Management:

Practical Concepts Steven J. Lieberson, DPM

ower extremity ulcerations are an ever-increasing problem in this country, particularly among those patients living with diabetes. Due to the continued surge in the disease’s presence throughout the general population (along with comorbidities of hypertension and obesity), the incidence of these ulcerations and secondary complications continues to grow over time. Despite advances in wound care, these ulcers remain very challenging to manage. Offloading, a removal of pressure from the site, is commonly needed on lower extremity ulcerations, as many of these ulcers occur on the bottom (plantar) aspect of the foot. This pressure cannot be removed per se, but rather be redistributed to help promote wound healing. This article seeks to discuss preliminary evaluation of a lower extremity ulcer, offloading, and surgical considerations.

ASSESSMENT & EXAMINATION

As with any wound that presents to the clinician, a thorough patient history and physical are needed to assess a lower extremity ulceration. By obtaining an accurate history, the clinician should be able to determine if the ulcer is acute, chronic, recurrent, or acute and likely to become chronic. A detailed history should contain all previous treatment modalities that may have helped or failed, provided the patient has a documented history of past wounds. A comprehensive history should also in-

clude any prescribed antibiotics (ie, oral, IV, topical, antibiotic bead placement). Consideration should also be made if the patient has experienced MRSA or if the patient has had any joint replacement or implant. Social history remains very important in developing a treatment protocol for a lower extremity ulceration. For example, one’s vocation or profession could limit ability to maintain offloading compliance. A thorough discussion between the healthcare provider and the patient is required to best decide upon a method of offloading that will provide the best opportunity for favorable outcomes to promote healing. Decisions also have to be made regarding how often dressings need to be changed with consideration to the wound and the overall activity level of the patient. As patients’ demands and limitations vary greatly, this remains a very challenging aspect of the treatment protocol. A thorough exam should include vascular, neurologic, orthopedic, and dermatologic evaluation. Complete blood count, metabolic panel, hemoglobin A1c, albumin, sedimentation rate, and wound culture comprise comprehensive lab work. Bone biopsy may also need to be performed. Imaging should include radiographs, bone scan, and possibly MRI. When a patient presents to clinic, overthe-counter devices are often employed to help offload the foot. These devices offer the ability to be readily available in the clinic to immediately begin to

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offload an area of pressure, proving effective for acute ulcerations; however, if the ulcer is chronic or is due to significant deformity, custom types of offloading will likely be required in the long term.

OPPORTUNITIES & OBSTACLES

A number of different options exist to perform offloading. These include: 1) Shoes and boots. One of the most common means of offloading foot ulcers remains the postoperative (surgical) shoe, which consists of a rigid wood bottom and Velcro straps to allow closure of the shoe. Beneficial in accommodating bandages from dorsal wounds, these shoes also help protect any compression bandage or hose that may also be worn on the lower extremity.The surgical shoe also helps remove pressure on the plantar aspect of the foot; however, other devices should be considered when plantar pressure needs to be limited due to an existing ulceration. The OrthoWedgeTM “healing shoe” is similar to the postop shoe, except for a wedge that’s placed either at the front of the foot (to offload the hindfoot) or vice versa.These shoes are superior in offloading for plantar ulcerations relative to surgical shoes, although, due to the wedge, patients may need to have a lift added to the unaffected foot to accommodate for relative limb length discrepancy that will now exist. Careful consideration needs to be given to the patient’s stability, and adjunct devices such as walkers may need to be used to prevent fall risk.

www.todayswoundclinic.com

6/8/12 11:05 AM

The pressure is off. Off of you, off the wound, off the patient.

Total Contact Cast System vs Other Off-Loading Modalities 3

TCC-EZ® eliminates those problems. It’s a best-in-class off-loading system providing: • A simpliﬁed casting process • Signiﬁcantly reduced application time • Greater patient comfort • Same optimal off-loading outcomes

100%

61.0

90% 80%

89.5%

50.4

70% 60% 50%

33.5

65.0%

58.3%

40%

30%

20% 10

10% 0%

Total Contact Removable Casting Cast/Walker

Mean Days to Complete Healing

Proper off-loading is one of the most important factors in managing diabetic foot ulcers. Total contact casting (TCC) is the one modality that has demonstrated optimal healing rates - in multiple controlled studies - and is recognized as the Gold Standard of Care in off-loading. But concerns regarding tissue damage, complex and time consuming application, and patient comfort have discouraged physicians from using TCCs.

Percent of Wounds Completely Healed

88% of wounds managed with total contact casting heal in 43 days.1 No other DFU therapy can say that.

Half Shoe

TCC-EZ® offers a one-piece, roll-on, woven design that simplifies the application process while reducing the potential for causing additional tissue damage. The result is a process that takes about ¼ the amount of time of traditional casting systems2,3 and a product that gives greater patient comfort. All while providing gold standard off-loading for optimal clinical outcomes. For a TCC-EZ® product demonstration, please contact your local representative or visit our website.

Quicker application. Greater comfort.

With TCC-EZ® it’s easy to take the pressure off.

www.dermasciences.com or call 800.445.7627 1.

Bloomgarden, ZT; American Diabetes Association 60th Scientific Sessions, 2000. Diabetes Care 24:946-951, 2001.

Bohne, G; Cost Effectiveness and Implementation of an Easy to Apply Total Contact System for Diabetic Grade 2 Neuropathic Foot Ulcers in Multi Physician Clinic. CSASWC Conference, 2009.

Shah, S; The Economics of Total Contact Casting. SAWC Spring Conference, April 2011.

Armstrong, et al; Diabetes Care, June 2001.

Scan this QR code now with your smart phone to view educational information and product videos on the TCC-EZ website.

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diabetes&wounds Cam Walker® and diabetic fracture walking boots are other viable options. Intended to fix the ankle relative to the leg, these devices help offload plantar ulcerations by removing propulsion from the gait cycle and are superior in relieving pressure on plantar ulcerations. Walking boots have an added honeycomb inset under the foot that’s secured with Velcro and can be easily removed to customize the bottom of the boot to relieve pressure directly under any existing ulcer. These boots are generally well tolerated by the patient, as they can be removed easily to allow bathing and necessary bandage changes. CROWs (Charcot Restraint Orthotic Walkers) are custom-molded, bivalved boots used to control patients with Charcot foot deformities. These boots can be removed for sleeping and bathing, and are generally well tolerated. They often feature a molded insert at the plantar foot that can be accommodated to the patient to maximize pressure relief on the bottom of the foot. These boots are best used for long-term control once an ulcer has healed or can be used if a small ulcer is present, as they will often fit a small bandage. 2) Shoe inserts. Extra-depth diabetic shoes provide a multidensity insert that helps offload the foot. These inserts can be customized to accommodate partial amputation and are commonly fitted with “fillers” that help reduce the space within the shoe from an amputated site. Shoe modifications may also be needed to further offload the plantar aspect of the foot. Steel bars may be added along the length of the sole of the shoe to prevent pressure on the forefoot from the rearfoot. Rocker bottoms are often added with a steel bar to help promote propulsion in a shoe by allowing the shoe to rock forward as opposed to having the flexibility in the shoe to allow propulsion but still limit plantar pressures. Ankle Foot Orthoses are L-shaped devices that incorporate control at the level of the ankle joint and are helpful in limiting plantar pressures. A drop foot brace, commonly used among stroke patients, is an example.This device fits in

a shoe and helps control plantarflexion of the foot at the ankle, thus limiting pressure, helping ulcers resolve or preventing them from recurring. These orthoses can be fixed, removing all motion across the ankle, or hinged (with or without a spring) to allow motion at the ankle to maintain greater level of function. 3) Total contact casting. These casts may be left in place for weeks at a time and allow “windows” to be created to provide access to a wound for bandage changes and treatments. Casting is often found to be cumbersome among patients, as bathing is rather difficult and access to the casted limb is prevented. 4) Weight-Bearing devices. Due to the nature of deformity and ulcer, complete offloading may be desired. The patient’s physical abilities and needs of daily living may limit the ability to perform this successfully. Commonly used in limiting weight-bearing of the lower extremity, crutches can present challenges. Many chronic wound patients live with multiple comorbidities and may lack the strength and conditioning needed to ambulate safely with crutches. Walkers also present a similar challenge in that they require a patient who is to be completely non-weight-bearing on a lower extremity to support body weight with only upper-body strength. Roll-A-Bout devices may be more secure for low-strength patients, but they still require enough strength in the contralateral extremity to ambulate safely. While wheelchairs allow patients to relieve pressure, they often present significant challenges among those who continue to work and/or lead more active lifestyles.

DETERMINing SURGERY

Clinicians must balance wishes, needs, comfort level and best chance of a patient’s healing success when choosing a method of offloading. At some point, despite all attempts, an ulcer may fail to heal. The extent of the underlying deformity may be so severe that surgical correction is needed, and many types of corrective procedures exist to relieve pressure and prevent amputation.

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Distal tip (toe) ulcerations can often be relieved by an arthroplasty at the proximal or distal inter-phalangeal joint, relieving pressure on the tip and preserving the toe. Lesser metatarsal ulcerations may be caused by retrograde pressure from an associated hammertoe deformity or by a deformity relating to the length or plantarflexion of the metatarsal. Bony prominences can often be relieved by a simple exostectomy. Tendon-balancing procedures may be needed in correcting a flexible deformity.These are only a few examples of the procedures available to the foot and ankle surgeon in correcting and underlying ulceration. In attempting to offload the foot and promote wound healing, the clinician should keep all options available. Offloading can be an art as much as a science. Modifications of the devices presented permit customizing that is only limited by the ideas of the clinician. Working closely with an orthotist will also be valuable when needing to modify a device. Referral to a foot-and-ankle surgeon should be conducted if attempts at offloading and proper wound care fail to provide adequate improvement. One other important thing to always consider: Offloading devices that can be easily removed and promote higher levels of comfort may also lead to noncompliance. Clinicians should inspect the condition of a patient’s offloading device during each visit to assess wear, or lack thereof. Oftentimes, if compliance is an issue, placing the patient in something more restrictive could actually be more productive. Additionally, remember that offloading often needs to be continued even after a wound has healed. Custom devices, which offer advanced comfort and limit risk of reoccurrence, are often employed at this time. n Steven J. Lieberson is in private practice in Houston and Sugar Land, TX. He is board certified by the American Board of Podiatric Surgery; is an attending clinician at the Advanced Wound Care Center, Houston; and serves as the academic chief and director of the podiatric medicine and surgical residency program at St. Joseph Medical Center in Houston.

www.todayswoundclinic.com

6/8/12 11:05 AM

Treating Painful Neuropathy Associated With Diabetes Richard Kobylar, DPM

n today’s healthcare scene there are many etiologies of neuropathy. None, however, is more prevalent than that which is related to diabetes, considering the growing global epidemic of the disease. Significant diabetic neuropathy typically occurs within 10 years of diagnosis and can increase throughout disease progression. “Painful” diabetic neuropathy is said to affect approximately 30% of all patients who experience diabetic neuropathy and significantly impact quality of life.1 Elevated blood sugars and the malevolent chemical changes cause impaired nerve function and damage the circulation to impacted nerves. This results in the classic symptoms of anesthesia and paresthesia: numbness, burning, tingling, “pins and needles,” and cramping sensations that are common among those patients who report to the wound clinic. These symptoms usually are at their worst during the eve-

ning hours and are especially problematic as a scenario of the anesthetic diabetic foot and its associated ulceration, infection, and risk of amputation. Treatment options for painful diabetic neuropathy have improved as our understanding of the complex pathology improves; however, the goals of treatment remain the same. Symptomatic relief of pain is the most obvious goal with peripheral neuropathy. This includes both short- and long-term medications as well as treatment plans designed to help the patient feel more comfortable. Slowing the progression of the disease is also necessary to prevent continued increase in required medication. Restoring function to the affected area of the body, as well as the body as a whole, is crucial to overall success. This article will discuss suggested treatment measures clinicians should know and can use to help alleviate neuropathic pain and improve quality of life.

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Improving Patient Habits

Trying to change a patient’s daily habits is one of the most frustrating challenges associated with treating diabetes and its complications. Before effective pharmaceutical therapy can be obtained, the diabetes should be brought under the best control possible. This consists of helping the patient establish sound glycemic control without variations, such as fluctuation of blood sugars, and reinforcing the importance of this standard through education. Consistently elevated glucose levels will only limit the results of treatment. Positive control measured with hemoglobin A1c and daily blood sugar reduces the overall risk of neuropathy. Exercise and weight loss further contribute to decreasing neuropathic pain, as does smoking cessation and limiting alcohol consumption. Patient education in these factors is also considered a must.

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diabetes&wounds “Painful” diabetic neuropathy is said to affect approximately 30% of all patients who experience diabetic neuropathy and significantly impacts quality of life.1

Topical & Oral Medications

There are numerous benefits to beginning topical therapy when used in combination with compliant blood glucose levels. Unfortunately, most oral medications have associated drug interactions and side effects when administered. Topical preparations limit systemic absorption and can still deliver effective pain control. Capsaicin, a product derived from hot chili peppers, is available as several over-the-counter strengths and brands and helps to reduce pain sensations by depleting substance P in the nerves. Lidocaine patches are another way clinicians can locally treat isolated symptomatic areas, and the side effects are minimal. Biofreeze, a menthol product, is available in gel, liquid, and spray form, and can be applied to areas of continued pain. Commonly dispensed by physicians, chiropractors, and physical therapists for an assortment of symptoms, Biofreeze seems to work well for neuropathy. L-arginine, an amino acid that has been the subject of recent study, is available orally and topically in a variety of commercial preparations. It is thought to stimulate vasodilation, increasing oxygen content in cells and improving overall circulation.2 A compounding pharmacy can also produce variations of products containing muscle relaxants, NSAIDS, anesthetics, and even pain medication into a dose that is applied topically. Many of these components were formally only available in oral form, but we’ve now learned the side effects and drug interactions can be limited. A variety of oral medications are currently available to help provide neuropathic pain relief when glycemic control and topical medications are not enough.

Many of the traditional medications used off-label have provided the best results for years. Anti-seizure medications, such as gabapentin, carbamazepine, and, most recently, pregabalin are used to treat disorders involving seizures (such as epilepsy). In addition, these medications have long been used for treating peripheral neuropathy with great success and can be titrated to the appropriate dose. Another class of medications that has shown benefits in the treatment of neuropathy is antidepressants. Amiltriptyline, imipramine, and nortriptyline work by interfering with the brain’s ability to interpret pain sensation. Initially, they are usually taken before bed and work well against overnight pain. Other antidepressants that inhibit reuptake of serotonin and norepinephrine, such as duloxetine, can also improve pain levels with fewer side effects. When necessary, opioid analgesics can be used for recalcitrant neuropathic pain. However, multiple side effects such as addiction, constipation, and sedation, as well as the need to increase the dose due to upregulation, make this class of medications less desirable.

Other Treatment Modalities

Methylcobalamin provides the active forms of folic acid and vitamins B6 and B12 directly to the body for functions such as DNA production, cell reproduction, and homocysteine metabolism to support peripheral nerve and blood vessel health. It can be taken twice daily and has no reported side effects, and is effective in treating symptomatic neuropathy. Methylcobalamin can also be used in combination with other pain medications with no significant interactions. Alpha-lipoic acid is a fatty acid and antioxidant that has also received attention lately. Studies are now underway in the

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area of its use for peripheral neuropathy. It can function in both water and fatty tissue, and therefore enter all parts of the nerve cell and protect it from damage while improving pain symptoms. Physical therapy modalities have also been shown to improve symptoms. Treatments such as transcutaneous electrical nerve stimulation units and massage, as well as continued rangeof-motion exercises, are important to maintain circulation. Anodyne Infrared Therapy Systems,® medical devices that are indicated to increase circulation and reduce pain, stiffness, and muscle spasm, emit infrared light from super-luminous light-emitting diodes across the therapy pads and are indicated for acute pain and poor circulation associated with both diabetes and vascular diseases. Studies indicate significant reduction in overall pain as well as being able to eliminate a patient’s dependence on pain medications.3 Acupuncture has been reported to be successful in relieving neuropathic pain in some patients, but according to sources4 takes multiple procedures, and results can vary per patient. Biofeedback is another alternative therapy in which patients are taught how to control certain body responses that reduce pain. These special machines are typically limited to larger hospitals and medical centers, and data has been found to be inconsistent. Spinal cord stimulators may offer assistance in the future for severe cases. Lastly, a nerve decompression technique pioneered by A. Lee Dellon, MD, PhD, has also been shown to improve peripheral neuropathy symptoms in patients when their neuropathy is due to a nerve entrapment, as is seen in diabetic neuropathy with associated nerve swelling. The procedure has been performed within institutions around the world with success.5 n Richard Kobylar is a podiatrist who practices in Baytown, TX. He may be reached at houstonfootdoctor@yahoo.com. References for this article can be accessed online at www.todayswoundclinic.com or by emailing jdarrah@hmpcommunications.com.

www.todayswoundclinic.com

6/8/12 11:08 AM

New Ideas For Your Paper The complexities of wound care management are unique. The WoundExpert software offers paperless, dynamic real-time collection, analysis, and visualization of your wound care program’s progress. And, as the industry’s first Certified EMR WoundExpert is the most complete clinical dataset and benchmarking solution available. Spend less time with paper and more time caring for the specific needs of your patients.

Net TWCAd.indd Health_0712.indd 1 1

5/24/12 6/6/12 11:32 5:14 AM PM

industryinsider An Inside Look at Net Health Systems Inc.

n interview with Christopher Hayes, chief technology officer.

Today’s Wound Clinic (TWC): How long have you been in wound care, and how did you enter this area of healthcare? Christopher Hayes (CH): I started with Net Health as an intern in the late 1990s and joined the company full time as the lead software developer on the WoundExpert software shortly thereafter. I’ve spent my entire professional career focused on making WoundExChristopher Hayes Chief Technology Officer, pert the most efNet Health Systems Inc. fective electronic medical record in the wound care space. I was the lead developer for nearly 10 years, giving me a very clear understanding of how we’ve grown to meet the needs of this industry and of the clinicians who make such a difference in their patients’ lives. TWC: What’s your day-to-day role? CH: As the chief technology officer, I am responsible for ensuring that what we are developing will meet the evolving needs of the marketplace. I spend my time meeting with current clients to understand how WoundExpert ties into their daily workflow; I meet with prospective customers to learn what issues they’re facing and to better understand how our product can grow; and I meet with leaders in the industry to hear their opinions about regulations,workflows,and

best practices for wound clinics. These conversations with clinicians, nurses, physicians, and program directors help ensure that every release of our product and every new feature is developed with the goals of improving clinical documentation,creating more efficient data entry, and empowering our hospital partners with better reporting capabilities. TWC:What do you find most rewarding about providing for your industry? CH: Our industry is filled with compassionate people who are serving patients whose lives have been completely interrupted. It is incredibly rewarding to help find ways to make their jobs easier – to ease their concerns about joint commission and reimbursement, to empower them to be able to track their own success, and to support their existing workflow - all with the express goal of allowing them to focus on patients. TWC: How would you describe the overall mission of your company? CH: Our mission is to provide operating excellence and innovation with a proven ability to meet and exceed client expectations. We have a very strong culture at Net Health, and as we grow we are careful to maintain our core values. We encourage innovation in the way we think, compete, collaborate and act; we believe in a healthy mixture of home, community, and profession; we push for experiences that offer growth and reward intelligent risk-taking; and we strive for accountability, responsiveness, and dedication. We spend a great deal of time finding

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the right people for the right jobs. We work with all new employees (at every level) to help them understand their own strengths and to provide outlets to ensure that they are maximizing those strengths in their current positions – each employee develops a personal mission, vision, and values statement and has “accountability partners” to help encourage them throughout the year. We have also designed all of the company’s artwork, which makes for a unique experience when visiting our Pittsburgh headquarters. For example, we have a Lichtensteinstyle piece that depicts a nurse saying, “WoundExpert is better than Hot Fudge!” TWC:What’s new with your company in 2012? CH: On the developmental front, we’re really excited about our new physician console. This user interface is specifically designed for physicians to help reduce their documentation time while effectively supporting billing and medical documentation needs. We worked with a wide range of physicians to fully understand the scope of their needs and determined that we needed to allow our physicians to have a personally configured workflow to ensure that WoundExpert is efficient for each of them. We’re in beta testing now, and the feedback has been phenomenal. We’re also very focused on further expanding our Wound Product Supplier Module this year. We just announced seven new vendors in WoundExpert, www.todayswoundclinic.com

6/7/12 5:16 PM

industryinsider and we continue to work with other durable medical equipment (DME) providers with the goal of all Wound Product Supply orders flowing from WoundExpert to effectively end the faxing inefficiencies. The mutual benefit to both our clinics and to the DME providers makes us very proud and excited to expand this connection. TWC: How is your company unique? CH: Our culture certainly sets us apart. By focusing on our employees’ growth, we create an environment where team members can provide our clients with an exceptional experience. Each individual knows he/she has strengths that can magnify the whole, and that is unique as well. WoundExpert is highly configured for each wound clinic to meet the way that they work best – we don’t define how they should provide care, and we don’t re-create the paper-chart environment. Instead, we ensure that our product seamlessly integrates with a hospital’s existing workflow – and each hospital is unique, much like our employees. In both cases, with our employees and with the clinics, we’re empowering people to do what they know best – we’re just providing the tools to make that easier. TWC: Why are you passionate about the work of your company? CH: I love knowing that we’re allowing wound clinics to harness otherwise unavailable information to help make better decisions. With paper records it would be nearly impossible to closely analyze each wound to determine if it is an outlier and a new intervention is needed, or to discover that your healing rate is above others in your peer group. It sounds trite, but in this case it is completely true that information is power. Our clinics have done a great job of embracing all this information that is at their fingertips and making a positive difference in patients’ lives every day. TWC: How is your company approaching challenges in wound care? CH: Changes in reimbursement are a

big concern for wound clinics right now. Through our robust reporting we’re helping them to see that they’re performing well, and to turn that high performance into accurate, timely reimbursement. WoundExpert is helping each of the medical directors and program directors prove the value of their wound clinic to hospital management. We’re also excited to help clinics understand when advanced therapies are needed. This is a direct result of our real-time clinical decision support and

“We work with all new employees (at every level) to help them understand their own strengths and to provide outlets to ensure that they are maximizing those strengths in their current positions – each employee develops a personal mission, vision, and values statement and has ‘accountability partners’ to help encourage them throughout the year.” advanced reporting functionality. Clinicians can easily determine when a wound is not healing at an acceptable rate and make the decision to proceed with advanced therapies. TWC: What are your most popular products and/or services? CH: WoundExpert offers outpatient wound clinics; dynamic, real-time collection; analysis; and visualization of a wound care clinic’s success.

www.todayswoundclinic.com

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We offer the most complete clinical dataset and benchmarking solution for wound management, supporting a 100 percent paperless patient record. Because our software is configurable to the facility’s needs, integration with existing hospital systems is easy and cost-effective.This combination of reporting,benchmarking, configurability, and integration is what our clients find most appealing. And,our clients really do get emotional about how this product has changed their lives,as evidenced by our aforementioned Lichtenstein-style artwork. TWC: How do you ensure proper training on products and services? CH: We are dedicated to ensuring that WoundExpert fits into a wound clinic’s workflow. To make that happen, WoundExpert trainers are onsite with our customers, in their clinics, working with them sideby-side. This isn’t something we think is negotiable – we provide this extra level of service because we strongly believe these clinicians,these physicians,these program directors are experts at what they do and our team simply needs to help integrate their customized WoundExpert into their operations. TWC: What are the future goals for you and your company? CH: We really want to provide more time for nurses and physicians to be with their patients. We know that the end game is 100 percent to enhance patient care. Every new advance we make to WoundExpert has that as the underlying goal. Of course, we believe that by giving more time to medical teams we are by default allowing them to improve their outcomes. What else could we really hope for as we continue to grow? n For more info on the WoundExpert or the company Net Health Systems Inc., call 800-411-6281 (option 2), visit www.woundexpert.com or email feedback@woundexpert.com.

Today’s Wound Clinic® June/July 2012

6/8/12 2:11 PM

Navigating The Inherient Dangers of Patient Referrals For many healthcare providers, making a referral can be a daunting risk. Does it have to be? Desmond Bell, DPM, CWS & Moira Hayes, MHA, RRT, CHT

ike any relationship, the bond between a healthcare provider and a patient is heavily based on faith, trust, and communication. Patients rely on their providers to be their advocates, to always have their best interests at the forefront, and to provide them with all the information needed regarding their care. Clinicians know this goes without saying. But do all wound care patients realize they equally need to communicate with their providers across the care continuum to give themselves the best chance at optimal outcomes, especially when they’re referred to another clinician for allied health services or consultation? Not likely. Often, providers must rely on their peers to effectively communicate information regarding their patients’ health. Unfortunately, this is not always a favorable outcome, according to a recent anonymous survey conducted by readers and the editorial board of Today’s Wound Clinic that reveals 46.5 percent of clinicians experience difficulty maintaining regular communication with their peers after a referral is made. (See Survey Stat No. 1. Additional survey results are presented throughout this article and are available at www.todayswoundclinic. com.) As troubling as this may be, there’s little more that can be done beyond making an individualized effort to promote the “team” approach to care. For clinicians who’ve been in Survey Stat No. 1: Do you find it’s difficult to maintain regular communication regarding your patients after you make a referral to a specialist?

No 53.5%

the profession for several years and/or have practiced in one community for a stretch of time, leadership may be needed to encourage patients and fellow providers to foster open lines of communication.

Referrals: Here to Stay

The wound care community has long espoused the importance of taking a team approach to treatment, and providing timely referrals is a critical aspect within the care continuum. Clinicians place a wealth of trust in fellow providers when seeking consultation. This establishment of trust is fundamental not only to patients’ well-being but to the trust that they, in turn, have for providers. Additionally, wound care clinicians need to make time to follow up with referred peers in order to build a comprehensive assessment of the patient throughout the care process. A new practitioner or one who is new to a community may struggle with a degree of trial and error when it comes to finding those specialists who provide top-quality care and communicate findings. In this article, two members of TWC’s editorial board offer a sampling of their experiences as they relate to the referral process and suggest how to establish as well as maintain trust among fellow providers and patients when a referral is necessary. n Survey Stat No. 2: In your experience, are patients: A) typically proactive in communicating with you as their primary provider after they’re referred to another specialist or B) leaving it strictly up to you to facilitate lines of communication?

Yes 46.5%

22 June/July 2012 Today’s Wound Clinic®

22_28_TWC_June-July_patient.indd 22

A 33.6% B 66.4%

www.todayswoundclinic.com

6/8/12 1:56 PM

The $20 Wound Care Solution Combine a PegAssist™ Insole with your DARCO MedSurg™ Shoe for the perfect Wound Care Solution - all for under $20! Your complete Wound Care Solution. The PegAssist™ System is built around a removable peg insole designed to fit Darco’s new Square Toe MedSurg™ Shoe. Each kit also includes a soft toe cover for closed-toe protection and a disposable lipstick tube to mark the off-loading site. Off-loads without Pressure Rings or Window Edema. Each insole has a 15mm Plastazote® base with a 3mm Poron® cover. When the plantar pegs are removed the Poron® top cover remains intact to eliminate pressure rings and instances of window edema.

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A true Multi-Purpose off-loading tool! In addition to its role in Wound Care the PegAssist™ Insole can also be modified to reduce pressure post-operatively or as a short-term pain management tool. To receive your FREE sample or to learn more about the PegAssist™ Insole System scan the QR code below or call us at 800-999-8866 and use offer code 1407A. (Clinicians only, one per practice.)

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patientreferrals The ‘I’ In ‘Team’ Desmond Bell, DPM, CWS

learned early in my career that wound care success is often dependent upon an appreciation and understanding of the variety of metabolic processes that my patients live with as complicating factors responsible for the development and persistence of their nonhealing wounds. Therefore, I quickly familiarized myself with the endocrinologists, cardiologists, neurologists, nephrologists, and vascular surgeons, for starters, when I began to practice in my region (Jacksonville, FL). I also began to realize that most of my patients were also under the care of primary physicians, nurse practitioners, and physician assistants. So, I’ve always made it a priority to remind all the providers with whom I’m making referrals or whom my patients are likely to come into contact with that hypertension, neuropathy, coronary artery disease, peripheral arterial disease, hypothyroidism, and renal disease, for starters, are common among my patient population. Looking back, it probably took me about six years to find the vascular specialist I’m most comfortable working with. Although we do not work in the same practice, the lines of communication between our practices and each

other are a stark contrast to what had been my prior referral pattern experience, which I’d describe as a “black hole” that was impersonal and never reassuring despite the solid reputations of the surgeons I came to know. There were instances when referrals would have the net effect of casting my patients into outer space. This aspect of not knowing surgeons personally was the result of factors I could appreciate, namely the time demands placed on them and the daily aspects of managing and working in a busy medical practice that I faced. More often than not, courtesy letters became a substitute for direct conversation.

Point of No Return

On more than one occasion, patients whom I had referred to a vascular specialist for consultation regarding an underlying concern of vascular insufficiency were not returning for their wound care. In several extreme instances, patients eventually arrived after undergoing a leg amputation, with no communication from the “consulting” surgeon. The flood of emotions associated with this type of perceived disrespect on my part only amplified the fact that my patients had trusted my role as a wound healer, but my efforts were undermined without as much as a phone call. I have heard stories from colleagues

Survey Stat No. 3: Have you ever made a referral to a specialist who did not refer your patient back to your care (ie, the specialist took over the wound care in addition to providing vascular intervention)?

No 28.8% Yes 71.2%

June/July 2012 Today’s Wound Clinic®

22_28_TWC_June-July_patient.indd 24

who’ve encountered similar situations that indicate there are specialists who are practicing within their own “silos” and are not embracing a team approach to wound care and limb preservation. I’m often baffled that such a pattern could persist despite the recognition of wound centers as providing a delivery system of care that surpasses what is typical of a physician’s office.

Earning Trust

Regardless, I’ve learned to attempt to gain the trust of patients during my first encounter with them by establishing dialogue that is of the two-way variety.When patients are engaged in their wound care, the odds of a successful outcome increase instinctively. I inform all patients that they’re critical to the wound care team and share a responsibility with other team members. This includes the need to communicate with me, whether that is regarding changes in their symptoms or an update following any visits they’ve had with another provider. As for developing interdisciplinary communication with providers, the importance of timely correspondence cannot be emphasized enough.Whether due to fear of losing patients, “turf wars” within the community, or simply poor communications skills, a failure to communicate between providers only breeds animosity. Ensuring this communication is easier said than done, but is nevertheless necessary. An easy phone call can allow you to emphasize your role as the coordinator of care between providers in an attempt to keep patients from becoming “lost.” Meanwhile, a mutual respect that’s built for each other’s work can quickly lead to increased referrals that benefit numerous patients and ofer you mutual introductions to a number of other providers in a variety of specialties both locally and nationally. By taking it upon myself to open lines of communication between my patients and my peers, I’ve come to the realization that referrals do not have to be wrought with fear of the unknown or the danger of losing a patient. I’ve taken control and know that I have im-

www.todayswoundclinic.com

6/8/12 1:57 PM

of De rmag rgarft s n io t a c li p p a De rma aft Wee kly f o s n io t a c li p p Wee kly a

For non-healing diabetic foot ulcers, consider the proven performance of Dermagraft with metabolically active living cells. www.dermagraft.com

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patientreferrals

Dermagraft : 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 fibroblastderived dermal substitute. (1) Intended Use/Indications: Dermagraft is indicated for use in the treatment of full-thickness diabetic foot ulcers greater than 6 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 6 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)

22_28_TWC_June-July_patient.indd 26

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 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 (3 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 salinebased cryoprotectant. This solution is supplemented with 10% DMSO (Dimethylsulfoxide) and bovine serum to facilitate long-term frozen storage of the product. Refer to the stepwise thawing and rinsing procedures to ensure delivery of a metabolically active product to a 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: Advanced BioHealing Customer Service: 1-877-Dermagraft (1-877-337-6247) Caution: Federal (U.S.) law restricts this device to sale by or on the order of a physician (or properly licensed practitioner). Manufactured and distributed by: Advanced BioHealing, Inc. 10933 N. Torrey Pines Road Suite 200 La Jolla, CA 92037 US PAT Nos 4,963,489; 5,266,480; 5,443,950 Dermagraft is a registered trademark of Advanced BioHealing, Inc. Registered in US Patent and Trademark Office ©2011 Advanced BioHealing, Inc. All Rights Reserved.

proved quality of care and have gained the recognition of my role as the conduit of such care among my patients and peers. n

Collaborating to Face Challenges Moira Hayes, MHA, RRT, CHT

opened a wound care and hyperbarics department in a small city 60 miles south of Houston, TX, in early 1997. The hospital was small, but we were fortunate to have a medical staff that was very diverse and could provide almost all the care our patients needed within one facility. We did not, however, have a vascular program, nor did we have interventional cardiologists. For two years, I searched the city of Houston, home of the country’s largest medical center and two medical schools, for a physician willing to perform vascular procedures on our patients. None of the physicians with whom I met were willing to care for our patient population. With the majority of our patients living with diabetic vasculopathy, placing stents and performing other vascular procedures “was not appealing” to these physicians. Instead, the surgeons I met with were interested in having a patent stent and good blood flow one year from the procedure and maintaining positive outcome statistics. Those results were not likely to happen with our patients. The outcome I was interested in remained getting the wounds healed while potentially allowing patients to avoid leg amputation. Our patients might not have had blood flow one year later, but they may still be walking.

Persistence Pays Off

By continuing to research and network, I ultimately met a vascular surgeon who practiced in Houston who was willing to

Survey Stat No. 4: Has a patient you’ve referred to a vascular specialist for intervention ever subsequently undergone an amputation by that specialist without communication by the specialist to you?

No 50.3%

Yes 49.7%

6/8/12 1:57 PM

The symposium on

adv an ced wound care

SAWC FALL

AAWC

The official meeting site of the Association for the Advancement of Wound Care

2012

September 12–14 B altimore Convention Center B altimore,

Maryland

Where Wound Care Clinicians Go For Answers

ver the last quarter century, the S ymposium on Advanced Wound Care (S AWC) has become internationally known as the premier educational program in wound care. N o other fall meeting has more programs and sessions geared to clinicians at wound care clinics. S AWC Fall offers up to 16 AMA PRA Category 1 Credits™, 41 new clinical sessions and a specific Wound Care Clinic track.

R obert Kirsner, MD, PhD V ice Chairman and S tiefel Laboratories P rofessor D epartment of D ermatology and Cutaneous S urgery U niversity of Miami Miller S chool of Medicine Miami, FL

D ot Weir, RN , CWON , CWS Clinical Coordinator, Wound Care O sceola R egional Medical Center Kissimmee, FL

TOP Se ssion s Y o u Won’t F ind A t O t her Wo und Care Conferen

ce s

• Crisis 2012: The P andemic O f Wounds • What Y ou S hould Know About D rugs That Inhibit Wound H ealing • D o Wound Clinics Benefit P atients? • Growth Factors And Advanced Therapies For Wounds: D oes The FD A E xpect Too Much? • N egative P ressure Wound Therapy: D o The D ata S uck? • E merging Treatments For D iabetic Foot U lcers • What’s D own The P ike For V enous Leg U lcers? • Getting P aid: The Finances O f Wound Care • R eality Check: What Y ou S hould Know About P alliative Wound Care • E merging Insights O n P ost-Amputation R ehabilitation

E ndorsed by the

F or more information and a full list of sessions, please visit www.sawcfall.com. Who Should A ttend: This conference is designed for physicians, researchers, podiatrists, nurses, physical therapists and dietitians involved in wound healing or wound care issues. S AWC Fall provides attendees who study and treat wounds with state-of-the-art reviews of clinical problems and research information. L earning O bjectives: After attending this conference, participants should be able to do the following: • Illustrate key factors that may delay or inhibit wound healing • E xamine proven and emerging scientific rationale behind wound care principles and how to translate them to clinical practice • D iscuss the latest advances in current and emerging diagnostic and healing techniques, and review ongoing or recently completed trials involving wound therapies • R ecognize the mechanisms behind the development of unusual wounds • Assess current and emerging healing techniques in wound care • Investigate critical elements associated with proper management of unusual and pediatric wounds, and review ongoing or recently completed clinical trials involving wound therapies • Appraise the evidence base of commonly used wound management strategies • E xplore the realities of delivering healthcare beyond clinical issues such as wound clinic office politics and the finances of wound care • P rovide optimal healthcare delivery through improved understanding of sites of service and payment schema

SAWC_FALL_2012_1-PAGE_TWC.indd 2

Acc reditation Information In support of improving patient care, N orth America Center for Continuing Medical Education, LLC (N ACCME), is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE ), and the American N urses Credentialing Center (AN CC) to provide continuing education for the healthcare team. Physicians: N orth American Center for Continuing Medical E ducation, LLC (N ACCME ), designates this live activity for a maximum of 16 AMA PRA Category 1 Credits™. P hysicians should claim only the credit commensurate with the extent of their participation in the activity. Nurses: This continuing nursing education activity awards 16.0 contact hours. P rovider approved by the California Board of R egistered N ursing, P rovider N umber 13255 for 16.0 contact hours. Podiatrists: N orth American Center for Continuing Medical E ducation, LLC (N ACCME ), is approved by the Council on P odiatric Medical E ducation as a sponsor of continuing education in podiatric medicine. This program is approved for 16 contact hours. Dietitians: N orth American Center for Continuing Medical Education, LLC (N ACCME), is a Continuing Professional Education (CPE ) Accredited Provider with the Commission on D ietetic R egistration (CDR ). R egistered dietitians (RD s) and dietetic technicians, registered (D TR s) will receive 16 continuing professional education units for completion of this program. CDR Accredited P rovider #HM 001 Level 3 S ynthesis Level

Physical T herapists: N orth American Center for Continuing Medical E ducation, LLC (N ACCME ), will apply for pre-approved accreditation in Florida, Louisiana, N evada, O hio, and Texas which require pre-approval. N ACCME will apply for pre-approval in California for targeted sessions. If you practice in another state, please consult your P T board. For questions regarding this educational activity, please call 609-371-1137. R equirements for Credit: To be eligible for documentation of credit for each session attended, participants must participate in the full activity and complete the online general survey and the online evaluation form for each session by O ctober 14, 2012. Complete the forms at www.myexpocredits. com/naccme; once done, participants may immediately print documentation of credit. Copyright © 2012 by N orth American Center for Continuing Medical E ducation, LLC. All rights reserved. N o part of this accredited continuing education activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from N orth American Center for Continuing Medical E ducation. ADA Statement: N orth American Center for Continuing Medical E ducation complies with the legal requirements of the Americans with D isabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call 609-371-1137. INFORMATION CONTAINED WIT HO UT NOTI CE .

HEREIN IS SUB JE CT TO CHAN GE

6/6/12 10:42 AM

patientreferrals Survey Stat No. 5: How would you BEST describe the relationship between wound care providers/podiatrists and vascular specialists in your community?

Nonexistent 4.3% Contentious 6.9%

Invaluable 11.8%

Mutually Respectful 28.3%

Sporadic 28.6%

Collegial 20.1% Survey Stat No. 6: When communication fails during the care continuum, do you more often believe it’s the patient or referred healthcare provider who’s Patient most culpable? 21.8%

Patient 21.8%

Provider 78.2%

accept our patients. It was a bit of a commute, but I believed it to be a valuable opportunity for patients. Within three months, he had cared for 18 patients.

It was the beginning of a wonderful working relationship, or so I thought. Unfortunately, he would go on to decide that many patients could have

other services performed at his office, namely wound care. Without provocation, patients we had been sending to him for vascular procedures were not returning to us for continuing wound management. After several discussions I had with the surgeon, we remedied the situation. The physician was willing to continue to see our patients while allowing us to follow up for wound care (after being reminded that it was much more lucrative for him to do vascular surgery on our patients and send them back to the clinic for wound care follow-up, as opposed to losing all of our referrals altogether). Today, our patients receive the care they need from the vascular surgeon as well as our staff in the clinic. I’m not naive to believe that our clinic’s experience was unique. With physician reimbursement decreasing, all physicians are looking for ways to expand their earning potential. Some communities don’t have access to all the specialties needed to care for complex patients like we all see in wound care. Medical staff politics can make referring patients outside the clinic treacherous. By refusing to let communication challenges get the better of me and my patients, I’m assuring those patients who are referred for specialized care outside of my clinic are cared for appropriately and comprehensively. I see the results and I make it a priority to follow up with each of them and their surgeon. n Desmond Bell is co-founder and executive director of Save A Leg, Save A Life Foundation. Moira Hayes is vice president of operations with HyperbaRXs LLC, Atlanta, GA.

online exclusive: Patient Referrals in Wound Care - Full Results TWC recently conducted an anonymous survey that was distributed at SAWC Spring 2012 and emailed to our readers and editorial board. A few numbers we calculated have been shared here. For full results, visit www.todayswoundclinic.com.

June/July 2012 Today’s Wound Clinic®

22_28_TWC_June-July_patient.indd 28

www.todayswoundclinic.com

6/8/12 1:57 PM

TWCnewsupdate New Wound Center Appoints Medical Director A new hospital-based outpatient wound center in California has named its medical director. Donato J. Stinghen, MD, has been appointed the position at the Kate Creedon Center for Advanced Wound Care, which is expected to open at Alameda Hospital the week of June 25. Hospital officials made the announcement May 30. Board certified in general surgery, Stinghen has practiced at the hospital 32 years. He previously served as president of the medical staff and chairman of the surgery committee. Stinghen received his doctoral degree from the Medical College of Wisconsin and graduated with honors from the University of California–Davis. He completed his internship and residency programs at Highland General Hospital in Oakland. In his position, he’ll lead a physician panel, participate in marketing activities, and provide governance over the utilization of clinical practice guidelines, officials said. “Don’s surgical and medical expertise, combined with his extraordinary leadership skills and passion for delivering the best possible outcomes, make him an ideal fit for this critically important position,” said Deborah Stebbins, Alameda’s chief executive officer. n

Vascular Surgeon Joins Wound Care Center

SPOTLIGHT ON: DIABETES Study Links Drug, Cancer Risk

Nowokere Esemuede, MD, has accepted a position at Wuesthoff Wound Care & Hyperbaric Center in Melbourne, FL. A fellowship-trained physician who’s board certified in vascular surgery and general surgery, he will work with general surgeon Emran Imami, MD, and family physician Lauren Romeo, MD.The center specializes in treatment of surgical wounds,diabetic ulcers,bone infections,vascular ulcers,venous stasis insufficiency, and radiation wounds. n

A study recently concluded by researchers in Canada has found an association between use of pioglitazone, a drug used to treat type 2 diabetes, and increased risk of bladder cancer. According to the findings, more than two years of daily exposure to pioglitazone doubles the risk of bladder cancer.The risks, however, are said to be low – up to 137 extra cases per 100,000 person years, according to researchers at the Lady Davis Institute at Jewish General Hospital, Montreal. No increased risk was seen with rosiglitazone, a similar drug within the thiazolidinediones class. Both drugs are reportedly known to increase the risk of heart failure. Using a database from patients in the United Kingdom (UK), the study included 115,727 people newly treated with diabetes drugs from 1988-2009. Results showed 470 patients were diagnosed with bladder cancer during the average 4.6 years of follow-up (a rate of 89 per 100,000 person years), researchers said. The rate of bladder cancer in the general UK population is reportedly 73 per 100,000 person years for those ages 65 and older. Full results can be found online at www.bmj.com/content/344/bmj.e3645. n

Pennsylvania Hospitals Adding Wound Care Centers A new wound care center is currently under construction and is expected to open in August at Waynesboro (PA) Hospital, an affiliate of Summit Health, Chambersburg, PA. According to a report published by the Herald-Mail newspaper, the center will specialize in treating chronic wounds. The hospital employs approximately 550 people. In Somerset, PA, an open house was recently held for the Advanced Wound Care Center, which is expected to open at Somerset Hospital in the next few weeks. Hospital administration is currently seeking a physician to run the facility, officials said. The center will be operated by Healogics, Jacksonville, FL, a wound care management company with more than 300 hospital partners. n

New Wound Center Commemorates Opening A ribbon-cutting ceremony was recently held for a new wound care center in Saranac Lake, NY. The Wound Care and Hyperbaric Treatment Center at Adirondack Medical Center, a $2.7 million facility, opened in late February. According to facility officials, patient visits are currently 25 percent higher than were expected at the time of the opening. n

www.todayswoundclinic.com

29_30_TWC_June/July_news.indd 29

Today’s Wound Clinic® June/July 2012

6/8/12 1:01 PM

TWCnewsupdate

classified

SPOTLIGHT ON: DIABETES New Treatments From Sanofi

RECR52A

We’re looking for an experienced Wound Services Manager

A wider range of diabetes treatment options is soon expected to be available by pharmaceutical company Sanofi. According to a recent report by Reuters, these treatments could address the disease as well as its numerous complications such as diabetic retinopathy. The company, which reported sales of around $5 billion in 2011 for its insulin Lantus, recently launched an iPhone-compatible device related to blood glucose monitoring. According to the report, Sanofi is also one of several drugmakers interested in acquiring Amylin Pharmaceuticals, San Diego, CA, a specialist in diabetic therapies that produces the drugs Byetta and Bydureon. Sanofi is also reportedly set to file for FDA approval of Lyxumia, a new experimental diabetes treatment, in the fourth quarter of 2012. n

IN THE KNOW: According to the Public Library of Sci-

ence, the likelihood of type 2 diabetes increases with waist size. Women with a large waist were almost 32 times more likely to develop the disease than those with a low-normal BMI and a smaller waist, while men with a large waist were 22 times more likely to develop the disease, a recent study shows.

Under the general supervision of the Director of Rehabilitation and Wound Services, the Wound Services Manager is responsible for outpatient wound care, hyperbaric oxygen (HBO) and physical therapy. The manager will be responsible for program development, personnel and work flow management, directing patient care activities, ensuring a safe work environment, quality patient care and customer service. The requirements for this position include a B.S./M.S. in nursing; eligible for licensure to practice Nursing in S.C. Must have three to five years of clinical experience with a minimum of two years’ supervisory experience and be ACLS certified, CWOCN preferred. Will consider other disciplines such as PT or MBA with wound center management experience. Spartanburg Regional is an integrated healthcare delivery system anchored by Spartanburg Regional Medical Center, a 540-bed teaching and research hospital. The system is unrivaled in its five-county service region, featuring world-class specialty centers, making it the region’s preferred provider of comprehensive healthcare services. If you are interested in joining an award-winning hospital, please forward your resume to Hospital Recruiter Elaine Jeter, RN, CHCR, ejeter@srhs.com or 800-288-7762. You may also visit our website at spartanburgregional.com.

EOE

29_30_TWC_June/July_news.indd 30

6/7/12 5:09 PM

INVESTIGATE

YOUR TEAM’S WOUND CARE REVENUE CYCLE

WCB2012 WOUND CLINIC BUSINESS

The nation’s premier event devoted to managing the wound care and hyperbaric oxygen therapy (HBOT) revenue cycles for hospital-based outpatient departments and physicians who work there. 2012 brings many new reimbursement and payment policy changes for wound care, HBOT departments and physicians. Even if you have attended a Wound Clinic Business meeting in previous years, you won’t want to miss this entirely new 2012 program, which highlights all the changes you must implement. • Investigate your REVENUE CYCLE TEAM’S knowledge of the ideal operational processes by following a patient through initial access/registration, assessment with management documentation requirements, charge capture and diagnosis and, finally, claim submission and payment. Then further your team’s knowledge of why and how to conduct internal audits pertaining to wound care and HBOT. • Which REVENUE CYCLE TEAM MEMBERS should attend? Medical directors, physicians and podiatrists, non-physician practitioners, program directors, clinical managers, therapists, billing directors, charge description master directors, HIM directors, coders, office managers, corporate compliance officers, revenue integrity auditors, and hospital executives.

Friday, June 8, 2012 Dallas, T exas Hyatt Regency DFW Friday, June 29, 2012 Chicago, Illinois DoubleTree O’Hare-Rosemont Friday, September 21, 2012 Cincinnati, Ohio Doubletree Cincinnati Airport Friday, October 26, 2012 Baltimore, Mar yland Hilton Baltimore Friday, November 2, 2012 Anaheim, California Hilton Irvine/Orange County Airport Friday, November 9, 2012 Orlando, Florida DoubleTree Hilton Orlando Downtown

Early-bird and group pricing available! Please visit www.woundclinicbusiness.com for additional information.

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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 References: 1. Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290-295. 2. Data on file, Organogenesis Inc. 3. Apligraf® [package insert]. Canton, MA: Organogenesis Inc; 2010.

Advertiser’s Index Advanced BioHealing �� 25, 26 Darco International �� 23 Derma Sciences �� 15 Healthpoint Biotherapeutics �� Cover 2 Intellicure Inc. �� 11 Medela Inc �� 3 Net Health Systems �� 19 Organogenesis_PI_0211.indd 1

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Organogenesis Inc. �� 32, Cover 4 PathoGenius Laboratories �� Cover 3 Progressive Wound Care Technologies �� 9 Sechrist Industries Inc. �� 5

June/July 2012 Today’s Wound Clinic®

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www.todayswoundclinic.com

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Potential Payment May Now Be Available for Every Application As of January 1, 2012, the Centers for Medicare and Medicaid Services (CMS) is eliminating the physician 90-day global surgical period for skin and dermal substitute procedures. For more information, please visit the News page on the Healthpoint Biotherapeutics website at www.healthpointbio.com/news.

Call our Reimbursement Navigation Hotline at 1-877-805-5005 for more information.

ÂŠ2012 Healthpoint Biotherapeutics Healthpoint is a registered trademark of Healthpoint, Ltd. TM1302-0112

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PathoGenius® . . . A S C E R TA I N A S D N A !

The proprietary DecodEx® test by PathoGenius® Laboratories comprehensively defines the wound bioburden, with DNA level certainty (including fungi).

MICROBIAL REALITY: • 99% of chronic wounds are polymicrobial, with high abundance. • Traditional cultures can identify < 5% of known microbes. Further, these microbes regularly make up < 1% of wound bioburden. • In a recent clinical trial (J Wound Care 2011: 20(5); 232), PathoGenius® testing in combination with patient specific topical gels, demonstrated a wound closure rate ~100% greater in every period, compared to traditional culture directed therapy (n = 1378 patients). Wolcott RD, Wound Healing Society April 2011

See us: WOCN Charlotte, June 10-12 Booth #1615 APMA Washington, August 16-18 Booth #2314

Guided by DNA, driven by patients.™ 1004 Garfield Drive, Bldg 340

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Lubbock, Texas 79416

806-771-1134

www.pathogenius.com

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After 4 weeks of failed conventional therapy— Rethink the Wound. Think Apligraf®.

Healing Wounds. Healing Lives. Act now for fast and complete healing of diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs).1-3 • Choose the ONLY bioengineered, bilayered, living cell–based product3 • Apligraf is the ONLY treatment indicated for both DFUs and VLUs3 • FDA approval for DFUs as early as 3 weeks3 • FDA approval for VLUs as early as 4 weeks3 • Frequent reassessment and reapplication of Apligraf as needed can signiﬁcantly improve the speed of healing and incidence of complete wound closure in DFUs and VLUs1-3

For information on support programs and tools available from Organogenesis Inc., call 1.888.HEAL.2.DAY (1.888.432.5232—Option 3) Please see accompanying essential prescribing information, or visit www.Apligraf.com for complete prescribing information

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