June/July 2012

Today’s

C o n t e m p o r a r y a p p r o a c h e s t o W o u n d C l i n i c M a n a g e m e n t

also in This issue:dangers of Patient ReferralsBusiness Briefs: Medicare summary notices

June/July 2012www.todayswoundclinic.com

Diabetes

LLC

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THE SYMPOSIUM ON ADVANCED WOUND CARE

SAWCFALL®

sawcfall.com

®

Focus on: Foot neuropathy, Disease control WounDs&

TWC_cover_00.indd 1 6/7/12 4:08 PM

Table of Contents • Feature Articles

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

Today’s

Addressing Diabetes Control: What Clinicians Must Know 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. Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA & Jason Hardage, PT, DPT, DScPT, GCS, NCS, CEEAA

8

®

Lower Extremity Ulcer Management: Practical Concepts

As the number of people living with diabetes climbs in the US, 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. Steven J. Lieberson, DPM

14

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

17

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

22

No53.5%

Yes46.5%

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®Today’s

EDIToRIAL STAff

CLINICAL EDIToRS AND foUNDINg boARDCaroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS

foUNDINg EDIToRIAL boARDKathleen Schaum, MSChristopher Morrison, MDVal Sullivan, PT, MS, CWS

MANAgINg EDIToR Joe Darrah [email protected]

WEb EDIToR Samantha [email protected]

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ExECUTIVE VICE PRESIDENTPeter [email protected]

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CLASSIfIED ADVERTISINg ASSoCIATE Christine Gabel [email protected]

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PRESIDENT BIll Norton

CoNTRoLLER Meredith Cymbor-Jones

VICE PRESIDENT, SPECIAL PRoJECTS Jeff Hall

MARKETINg MANAgERStephanie Manzo

CREATIVE DIRECToR Vic [email protected]

ART DIRECToR Bernadette [email protected]

SENIoR PRoDUCTIoN MANAgERAndrea [email protected]

PRoDUCTIoN/ CIRCULATIoN DIRECToR Kathy [email protected]

AUDIENCE DEVELoPMENT MANAgERBill Malriat

MEETINg PLANNER Tracy Blithe, CMP

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ChIEf ExECUTIVE offICERJeff Hennessy

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SR. MANAgER, ITKen Roberts

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TWC Onlinewww.todayswoundclinic.com

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

6 business briefs Are You Prepared to Answer Questions About New Medi-

care Summary Notices? Kathleen D. Schaum, MS

20 Industry Insider An inside look at Net Health Systems Inc.

29 TWC News Update Study links diabetes drug, cancer;

PA hospitals add wound centers

32 Advertiser Index

Exclusive: Meet our Editorial boardToday’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 ResultsThanks to all who participated in our most recently emailed survey: “Pa-tient Referrals in Wound Care.” We’ve compiled all the results, and they can only be found online.

Table of Contents

83 General Warren Boulevard, Suite 100, Malvern, PA 19355Editorial 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 in-herent 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 practi-tioners are invited and will be subject to Editorial Board review.

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

Follow us on Twitter: @TWCjournal

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

1-2_TWC_June/July_TOC.indd 2 6/7/12 5:25 PM

SIMPLIFYING NEGATIVE PRESSURE WOUND THERAPY

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4 June/July 2012 Today’s Wound Clinic®

Today’s®

Editorial Board

Founding Editorial Board MEMBErs

Co-Editor oF today’s Wound CliniCCaroline Fife, MD, FAAFP, CWS

Co-Editor oF today’s Wound CliniC Dot Weir, RN, CWON, CWS

Christopher A. Morrison, MD, FACHM, FCCWS

Valerie Sullivan, PT, MS, CWS

Kathleen D. Schaum, MS

Editorial Board MEMBErs

Andrew J. Applewhite, MD, CWS, UHM

Leah Amir, MS, MHA

Desmond Bell, DPM, CWS

Trisha Carlson, MSN, MBA-HCM, RN, CWCN

Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA

Moira Hayes, MHA, RRT, CHT

Cathy Thomas Hess, BSN, RN, CWOCN

Harriet Jones, MD, BSN, FAPWCA

Robert S. Kirsner, MD, PhD

Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA

Pamela Scarborough, PT, DPT, MS, CDE, CWS

Susie Seaman, NP, MSN, CWOCN

Tere Sigler, PT, CWS, CLT-LANA

Pamela G. Unger, PT, CWS, FCCWS

Randall Wolcott, MD, CWS

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 Commu-nications, LLC (HMP) is the authoritative source for comprehensive informa-tion 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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A patient of mine developed a popular prescription drug that’s frequently ad-vertised 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 undi-agnosed diabetes, with other possibilities including B12 deficiency or too many martini lunches. Despite his bril-liance, it took a lot of convincing for him to agree to 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.

FOCUS ON FEETGiven 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 hy-perglycemia 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 patho-physiology 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 attend-ees 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.,[email protected]

introduction

Caroline FifeCo-Editor of TWC

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Sechrist_0910_2009_reprocessed:7.875 x 10.75 ad page 10/14/09 2:37 PM Page 1

6 June/July 2012 Today’s Wound Clinic® www.todayswoundclinic.com

businessbriefsAre 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 accu-racy 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.

Wound care providers and sup-pliers are accustomed to two things: 1) submitting claims to

Medicare for services and products pro-vided 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 ben-eficiaries about their claims for Medicare services and benefits.

All wound care providers and their staff should always: 1) ascertain whether ques-tions 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 hospital-based outpatient wound care department (HOPD), the patient will receive two bills: one from the wound care profes-sional and one from the HOPD. In that circumstance, you must clarify whether the patient’s question is regarding the pro-fessional 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, separate-ly payable drug/biologic, separately payable equipment, and separately payable supply received on a given date of service. Each year Medi-care 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, pro-cedures, and separately payable prod-ucts 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 coinsur-ance you may owe, if you do not have supplemental insurance. Medi-care 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 avail-able 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 Medi-care 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 insur-ance (Medigap) plan or other insurer. That plan may pay your share.

6_7_TWC_June/July_business.indd 6 6/7/12 4:21 PM

www.todayswoundclinic.com Today’s Wound Clinic® June/July 2012 7

businessbriefsthe wound provider/supplier may resubmit the Medicare claim and/or supplemental insurance claim.

• If there’s a disagreement with any de-cision made by Medicare or supple-mental 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. Fol-lowing 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 Medi-care has or has not covered and provides information about the beneficiary’s pay-ment 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 af-ter the CMS announcement to Medicare beneficiaries. Early in 2013, paper copies of the redesigned MSN will start to re-place the current version that is mailed to beneficiaries on a quarterly basis.

The redesigned MSN includes several features that are new to Medicare ben-eficiaries, 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 ben-eficiary’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

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 de-ductible status, their coinsurance respon-sibility, their right to appeal (including clear appeal instructions), and straightfor-ward instructions for reporting suspected Medicare fraud. Beneficiaries will also be

empowered to challenge their provider and/or supplier charges and to report suspected Medicare fraud (with the pos-sibility of receiving a reward). Therefore, wound care providers and staff should take the time to understand the rede-signed 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 [email protected].

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 Medi-care 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 oth-er charges not covered. If you have Medicare Supple-ment Insurance (Medigap policy) or other insurance, it may pay all or part of this amount.

6_7_TWC_June/July_business.indd 7 6/7/12 4:21 PM

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

Addressing diAbetes Control: WhAt CliniCiAns Must KnoW

While many comorbidities have the potential to impact wound healing, this is especially true of

diabetes mellitus (DM), a common dis-ease among patients living with wounds. The impairments related to the disease state of DM affect all wound etiologies and impair all phases of healing. Health-care 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 coordi-nates 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 epidemi-ology, its effects on healing, the clinical challenges it poses, and considerations for wound care clinicians. (For informa-tion on pathophysiology, consult other sources, including standards of care by the American Diabetes Association.1)

EpidEmiology & implicationsDM has been at epidemic levels

worldwide for some time,2,3 having far-reaching 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 experienc-ing DM-related complications, includ-

ing wound healing issues. Current evi-dence demonstrates that DM inhibits all phases of wound healing via impaired function of the primary cells respon-sible for wound repair (ie, neutrophils, macrophages, and fibroblasts), frequent-ly 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 glyco-solated end products, nitric oxide dys-function, decreased insulin availability or increased insulin resistance, and altered homocysteine levels also contribute to the complex host of impairments that affect healing. Microvascular and macro-vascular, neuropathic, immune function, biochemical, and hormonal abnormali-ties contribute to the altered tissue-re-pair processes in people with DM and hyperglycemia.6 One example of a DM-mediated impairment in wound heal-ing is susceptibility to infection. Under normal conditions, during the coagu-lation 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 inflamma-tory 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 in-fection. In fact, people living with DM

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 ongo-ing.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, multifac-eted pathophysiologic relationship be-tween 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:

• Diabetes Self-Management Ed-ucation/Training (DSME/T): Defined by the American Associa-tion of Diabetes Educators as a col-laborative process through which people living with or at risk of DM gain the knowledge and skills needed to modify behavior and suc-cessfully self-manage the disease and


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diabetes&wounds

its related conditions (see Table 2).10 Aims to achieve optimal health sta-tus, 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-solv-ing are crucial.10 Standards of care require patients receive self-manage-ment education upon diagnosis.1,15

• Medical Nutrition Therapy (MNT): The preferred term when referring to nutrition interven-tions, as opposed to “diabetic diet,” “diet therapy,” or “dietary manage-ment.” 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 individ-ual lifestyle and behavior changes that will lead to improved meta-bolic 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-threat-ening hypoglycemic events. Asso-ciated complications (eg, diabetic retinopathy, diabetic neuropathy, or diabetic nephropathy) may neces-sitate certain precautions and con-traindications for PA. Where there are musculoskeletal, neuromuscular, or cardiovascular impairments, a referral to a physical therapist may be appropriate.9

• Pharmacological Management: The drug armamentarium for gly-

Table 1. Diabetes in the US4

• 25.8 million: Total population living with DM:o 1.29 million: Population with T1DM diagnosedo 17.5 million: Population with T2DM diagnosedo 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

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


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diabetes&wounds

cemic control for patients living with DM is fairly large and grow-ing 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 dis-eases with the similar outcome of hyperglycemia.8 Medications com-prise oral classes and injectables, in-cluding insulin.

• Monitoring of Glycemic Sta-tus: As performed by patients and healthcare providers, a cornerstone of DM care. Results are used to as-sess efficacy of overall management, to guide adjustments to MNT and exercise, to determine effectiveness of the medical plan regarding med-ications, and to determine how ill-ness 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 ef-fectiveness 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 labora-tory test, the glycosylated hemo-globin 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 PatientsThere are many challenges in provid-

ing care for this patient population. No-table issues include those related to:

1) Education. Patients require educa-tion 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 comprehen-sive DSME/T program;1,15 howev-er, many patients do not have ac-

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 deficien-cy 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 depres-sion.16 With depression, DM self-management can become severely compromised, depending on the in-dividual’s coping abilities, presenting more challenges for healing. Diabetes conveys psychological, social, and fi-nancial burdens on the affected indi-vidual. The wound brings additional psychological, social, and financial burdens.8 Burnout (ie, a sense of emotional exhaustion, depersonaliza-tion, reduced personal accomplish-ments) 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 “sab-otaging” the care plan. The psychoso-cial impact of DM is life-altering, es-pecially with the addition of chronic complications that frequently accom-pany 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 label-ing someone as “non-compliant” or “non-adherent,” the wound care cli-nician should assess whether the pa-tient has a functional DM manage-ment plan individualized to his or her needs and whether the patient knows how to self-manage the DM,

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.



diabetes&wounds

providing an appropriate referral as needed. Doing so promotes an en-vironment 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 nec-essary 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 self-management as a lifelong process, and help the patient understand the ben-efits, including improved wound heal-ing, that make the hard work worth-while. This approach promotes rapport and open communication.

Wound Care CliniCian’s roleThe initial examination of the pa-

tient and wound should include a ba-sic assessment of the DM management plan. The following questions are some intake components to consider:

• Have you had a series of DM self-management 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 be-ta-cell failure than when he or she first started treatment for DM. Be-cause T2DM is progressive, lifestyle management or oral medications initially prescribed may no longer provide the control they once did. The wound care clinician may rec-ognize or suspect the medications are not providing needed coverage. Thus, a referral is necessary for eval-uation of the need to add another oral medication or start insulin, es-pecially 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-

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 sta-tus changes or signs of abuse and/or neglect that impact self-manage-ment. 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 in-clude self-monitoring of BG, nutrition and hydration, and PA. Clinicians should keep the DM-related assessment manage-able and remember their role in assessing the success of the patient’s self-manage-ment 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 as-sistant 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 [email protected].

Figure 1. Correlation of A1c Values with Average Glucose1

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A1c

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Steven J. Lieberson, DPM

Lower extremity ULcer management:

PracticaL concePts

Lower 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 pop-ulation (along with comorbidities of hypertension and obesity), the inci-dence of these ulcerations and second-ary complications continues to grow over time. Despite advances in wound care, these ulcers remain very challeng-ing 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 & EXAMINATIONAs 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 his-tory should contain all previous treat-ment 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 replace-ment or implant. Social history remains very important in developing a treat-ment protocol for a lower extremity ul-ceration. For example, one’s vocation or profession could limit ability to main-tain offloading compliance. A thor-ough discussion between the healthcare provider and the patient is required to best decide upon a method of offload-ing that will provide the best opportu-nity 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 treat-ment protocol.

A thorough exam should include vas-cular, neurologic, orthopedic, and der-matologic 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 ra-diographs, bone scan, and possibly MRI. When a patient presents to clinic, over-the-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

offload an area of pressure, proving effec-tive 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 & OBSTACLESA 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 accommodat-ing 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 pres-sure needs to be limited due to an exist-ing 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 offload-ing for plantar ulcerations relative to sur-gical 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 ad-junct devices such as walkers may need to be used to prevent fall risk.

14_16_TWC_June-July_feature2.indd 14 6/8/12 11:05 AM

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

www.dermasciences.com or call 800.445.76271. Bloomgarden, ZT; American Diabetes Association 60th Scientifi c Sessions, 2000. Diabetes Care 24:946-951, 2001.2. 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, 2009.3. Shah, S; The Economics of Total Contact Casting. SAWC Spring Conference, April 2011.4. Armstrong, et al; Diabetes Care, June 2001.

© 2012 Derma Sciences, Inc. All rights reserved..

Total Contact Cast Systemvs Other Off-Loading Modalities3

Quicker application. Greater comfort.

100%

90%

80%

70%

60%

50%

40%

30%

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33.533.533.533.533.533.533.533.533.533.5

50.4

Removable Half Shoe Cast/Walker

70

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Total Contact Casting

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

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

TCC-EZ® offers a one-piece, roll-on, woven design that simplifi es 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.

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

Scan this QR code now with your smart phone to view educational

information and product videos on the TCC-EZ website.

DermaSciences_TCC_0612.indd 1 6/18/12 1:24 PM


diabetes&woundsCam Walker® and diabetic fracture

walking boots are other viable options. Intended to fix the ankle relative to the leg, these devices help offload plan-tar ulcerations by removing propulsion from the gait cycle and are superior in relieving pressure on plantar ulcerations. Walking boots have an added honey-comb 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 exist-ing ulcer. These boots are generally well tolerated by the patient, as they can be removed easily to allow bathing and nec-essary bandage changes.

CROWs (Charcot Restraint Or-thotic 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 need-ed 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 of-ten added with a steel bar to help pro-mote 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 pres-sure, helping ulcers resolve or prevent-ing 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 pa-tients, 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 liv-ing 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 mul-tiple comorbidities and may lack the strength and conditioning needed to am-bulate 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 extrem-ity to support body weight with only up-per-body strength. Roll-A-Bout devic-es may be more secure for low-strength patients, but they still require enough strength in the contralateral extremity to ambulate safely. While wheelchairs al-low patients to relieve pressure, they of-ten present significant challenges among those who continue to work and/or lead more active lifestyles.

DETERMININg SURgERYClinicians must balance wishes,

needs, comfort level and best chance of a patient’s healing success when choos-ing a method of offloading. At some point, despite all attempts, an ulcer may fail to heal.

The extent of the underlying defor-mity may be so severe that surgical cor-rection is needed, and many types of corrective procedures exist to relieve pressure and prevent amputation.

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 preserv-ing 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 op-tions available. Offloading can be an art as much as a science. Modifications of the devices presented permit custom-izing 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 ad-equate 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 non-compliance. Clinicians should inspect the condition of a patient’s offloading device during each visit to assess wear, or lack thereof. Oftentimes, if compli-ance is an issue, placing the patient in something more restrictive could actu-ally be more productive.

Additionally, remember that offload-ing often needs to be continued even af-ter 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 certi-fied 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.


Richard Kobylar, DPM

TreaTing Painful neuroPaThy associaTed WiTh diabeTes

in today’s healthcare scene there are many etiologies of neuropathy. None, however, is more prevalent than that

which is related to diabetes, consider-ing the growing global epidemic of the disease. Significant diabetic neuropathy typically occurs within 10 years of di-agnosis and can increase throughout dis-ease progression. “Painful” diabetic neu-ropathy is said to affect approximately 30% of all patients who experience dia-betic neuropathy and significantly im-pact quality of life.1 Elevated blood sug-ars and the malevolent chemical changes cause impaired nerve function and dam-age 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 com-mon among those patients who report to the wound clinic. These symptoms usually are at their worst during the eve-

ning hours and are especially problemat-ic as a scenario of the anesthetic diabetic foot and its associated ulceration, infec-tion, and risk of amputation. Treatment options for painful diabetic neuropathy have improved as our understanding of the complex pathology improves; how-ever, the goals of treatment remain the same. Symptomatic relief of pain is the most obvious goal with peripheral neu-ropathy. This includes both short- and long-term medications as well as treat-ment plans designed to help the patient feel more comfortable. Slowing the progression of the disease is also nec-essary 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 suggest-ed treatment measures clinicians should know and can use to help alleviate neu-ropathic pain and improve quality of life.

imProving PaTienT habiTsTrying to change a patient’s daily hab-

its is one of the most frustrating chal-lenges 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 stan-dard 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 neu-ropathic pain, as does smoking cessa-tion and limiting alcohol consumption. Patient education in these factors is also considered a must.


17_18_TWC_June-July_feature3.indd 17 6/7/12 5:30 PM


diabetes&wounds

Topical & oral MedicaTionsThere are numerous benefits to be-

ginning topical therapy when used in combination with compliant blood glucose levels. Unfortunately, most oral medications have associated drug interactions and side effects when ad-ministered. 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 avail-able 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 va-riety of commercial preparations. It is thought to stimulate vasodilation, in-creasing oxygen content in cells and improving overall circulation.2

A compounding pharmacy can also produce variations of products con-taining muscle relaxants, NSAIDS, anesthetics, and even pain medication into a dose that is applied topically. Many of these components were for-mally 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 cur-rently available to help provide neuro-pathic pain relief when glycemic control and topical medications are not enough.

Many of the traditional medications used off-label have provided the best re-sults 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 periph-eral neuropathy with great success and can be titrated to the appropriate dose. Another class of medications that has shown benefits in the treatment of neu-ropathy is antidepressants.

Amiltriptyline, imipramine, and nor-triptyline work by interfering with the brain’s ability to interpret pain sensa-tion. Initially, they are usually taken before bed and work well against over-night pain. Other antidepressants that inhibit reuptake of serotonin and nor-epinephrine, such as duloxetine, can also improve pain levels with fewer side effects. When necessary, opioid analge-sics can be used for recalcitrant neuro-pathic pain. However, multiple side ef-fects 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 ModaliTiesMethylcobalamin provides the active

forms of folic acid and vitamins B6 and B12 directly to the body for functions such as DNA production, cell reproduc-tion, and homocysteine metabolism to support peripheral nerve and blood ves-sel health. It can be taken twice daily and has no reported side effects, and is effec-tive in treating symptomatic neuropathy.

Methylcobalamin can also be used in combination with other pain medica-tions with no significant interactions. Alpha-lipoic acid is a fatty acid and an-tioxidant that has also received attention lately. Studies are now underway in the

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. Physi-cal therapy modalities have also been shown to improve symptoms.

Treatments such as transcutaneous electrical nerve stimulation units and massage, as well as continued range-of-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 di-abetes and vascular diseases. Studies indi-cate significant reduction in overall pain as well as being able to eliminate a pa-tient’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 re-sponses 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 neu-ropathy is due to a nerve entrapment, as is seen in diabetic neuropathy with as-sociated nerve swelling. The procedure has been performed within institutions around the world with success.5 n

Richard Kobylar is a podiatrist who prac-tices in Baytown, TX. He may be reached at [email protected].

References for this article can be accessed online at www.todayswoundclinic.com or by emailing [email protected].

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


New Ideas For Your PaperThe 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.

WoundExpert.com© 2012 Net Health Systems, Inc. WoundExpert is a Registered Trademark of Net Health Systems, Inc.

TWCAd.indd 1 5/24/12 11:32 AMNet Health_0712.indd 1 6/6/12 5:14 PM


industryinsiderAn Inside Look at Net Health Systems Inc.

A 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 soft-ware shortly there-after.

I’ve spent my entire professional career focused on making WoundEx-pert the most ef-fective electronic

medical record in the wound care space. I was the lead developer for nearly 10

years, giving me a very clear understand-ing of how we’ve grown to meet the needs of this industry and of the clini-cians 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 prod-uct and every new feature is developed with the goals of improving clinical docu-mentation, creating more efficient data en-try, and empowering our hospital partners with better reporting capabilities.

TWC: What do you find most reward-ing about providing for your industry?

CH: Our industry is filled with com-passionate people who are serving pa-tients 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 oper-ating 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, com-pete, 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 account-ability, responsiveness, and dedication.

We spend a great deal of time finding

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 “ac-countability 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 Lichtenstein-style 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 phy-sician console.

This user interface is specifically de-signed for physicians to help reduce their documentation time while effectively supporting billing and medical docu-mentation needs.

We worked with a wide range of physi-cians to fully understand the scope of their needs and determined that we needed to allow our physicians to have a per-sonally configured workflow to ensure that WoundExpert is efficient for each of them.

We’re in beta testing now, and the feed-back has been phenomenal.

We’re also very focused on further ex-panding our Wound Product Supplier Module this year. We just announced seven new vendors in WoundExpert,

Christopher Hayes Chief Technology Officer, Net Health Systems Inc.

20_21_TWC_June/July_industry.indd 20 6/7/12 5:16 PM


industryinsiderand 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 ben-efit to both our clinics and to the DME providers makes us very proud and ex-cited 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 mag-nify 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 seam-lessly 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 allow-ing 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 com-pletely true that information is power. Our clinics have done a great job of em-bracing all this information that is at their fingertips and making a positive differ-ence in patients’ lives every day.

TWC: How is your company ap-proaching challenges in wound care?

CH: Changes in reimbursement are a

big concern for wound clinics right now. Through our robust reporting we’re help-ing 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 un-derstand when advanced therapies are needed. This is a direct result of our real-time clinical decision support and

advanced reporting functionality. Clini-cians can easily determine when a wound is not healing at an acceptable rate and make the decision to proceed with ad-vanced therapies.

TWC: What are your most popular products and/or services?

CH: WoundExpert offers outpatient wound clinics; dynamic, real-time collec-tion; analysis; and visualization of a wound care clinic’s success.

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 exist-ing hospital systems is easy and cost-effec-tive. This combination of reporting, bench-marking, 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 side-by-side.

This isn’t something we think is ne-gotiable – 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 [email protected].

“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.”

20_21_TWC_June/July_industry.indd 21 6/8/12 2:11 PM

For many healthcare providers, making a referral can be a daunting risk. Does it have to be?

NavigatiNg the iNherieNt DaNgers of PatieNt referrals

like any relationship, the bond between a healthcare pro-vider 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 fore-front, and to provide them with all the information needed regarding their care. Clinicians know this goes without say-ing. But do all wound care patients realize they equally need to communicate with their providers across the care con-tinuum to give themselves the best chance at optimal out-comes, 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 cli-nicians experience difficulty maintaining regular communi-cation with their peers after a referral is made. (See Survey Stat No. 1. Additional survey results are presented through-out 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

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 stayThe wound care community has long espoused the impor-

tance 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 funda-mental not only to patients’ well-being but to the trust that they, in turn, have for providers. Additionally, wound care cli-nicians 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 sam-pling 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


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

No53.5%

Yes46.5%

B66.4%

A33.6%

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?

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?

22_28_TWC_June-July_patient.indd 22 6/8/12 1:56 PM

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patientreferrals

I 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 familiar-ized myself with the endocrinologists, cardiologists, neurologists, nephrolo-gists, and vascular surgeons, for starters, when I began to practice in my region (Jacksonville, FL). I also began to real-ize that most of my patients were also under the care of primary physicians, nurse practitioners, and physician assis-tants. So, I’ve always made it a priority to remind all the providers with whom I’m making referrals or whom my pa-tients are likely to come into contact with that hypertension, neuropathy, coronary artery disease, peripheral ar-terial 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 spe-cialist I’m most comfortable working with. Although we do not work in the same practice, the lines of communica-tion between our practices and each

other are a stark contrast to what had been my prior referral pattern expe-rience, 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 pa-tients 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 prac-tice that I faced. More often than not, courtesy letters became a substitute for direct conversation.

PoInt of no RetuRnOn more than one occasion, patients

whom I had referred to a vascular spe-cialist for consultation regarding an underlying concern of vascular insuf-ficiency were not returning for their wound care. In several extreme in-stances, patients eventually arrived after undergoing a leg amputation, with no communication from the “consulting” surgeon. The flood of emotions associ-ated with this type of perceived disre-spect on my part only amplified the fact that my patients had trusted my role as a wound healer, but my efforts were un-dermined without as much as a phone call. I have heard stories from colleagues

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 tRustRegardless, I’ve learned to attempt

to gain the trust of patients during my first encounter with them by establish-ing dialogue that is of the two-way va-riety. 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 respon-sibility 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 pro-vider. As for developing interdisciplin-ary 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 com-municate between providers only breeds animosity. Ensuring this communication is easier said than done, but is neverthe-less necessary. An easy phone call can al-low you to emphasize your role as the coordinator of care between providers in an attempt to keep patients from be-coming “lost.” Meanwhile, a mutual re-spect 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 special-ties 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-

the ‘I’ In ‘team’ Desmond Bell, DPM, CWS

No28.8%

Yes71.2%

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)?


Weekly applications of Dermagraft

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

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DermaScience_Medihoney_1111.indd 1 10/26/11 10:49 AM

patientreferrals

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

I opened a wound care and hyperbarics department in a small city 60 miles south of Houston, TX, in early 1997. The hos-pital 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 cardiolo-gists. 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 will-ing 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 inter-ested in having a patent stent and good blood flow one year from the procedure and maintaining positive outcome statis-tics. 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 amputa-tion. Our patients might not have had blood flow one year later, but they may still be walking.

PersIstenCe Pays OFFBy continuing to research and network, I ultimately met a

vascular surgeon who practiced in Houston who was willing to

No50.3%

Yes49.7%

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?

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

Numbers in parentheses ( ) refer to sections in the Directions for Use of the product labeling.Device Description: Dermagraft is a cryopreserved human fibroblast-derived dermal substitute. (1)Intended Use/Indications: Dermagraft is indicated for use in the treatment of full-thickness diabetic foot ulcers greater than 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)

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 saline-based cryoprotectant. This solution is supplemented with 10% DMSO (Dimethylsulfoxide) and bovine serum to facilitate long-term frozen storage of the product. Refer to the step-wise thawing and rinsing procedures to ensure delivery of a metabolically active product to 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 RoadSuite 200 La Jolla, CA 92037US PAT Nos 4,963,489; 5,266,480; 5,443,950Dermagraft is a registered trademark of Advanced BioHealing, Inc. Registered in US Patent and Trademark Office©2011 Advanced BioHealing, Inc.All Rights Reserved.

Dermagraft®

: Human Fibroblast-Derived Dermal Substitute Essential Prescribing Information


AAWC

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

The symposium on Adv An Ced Wound CAre

2012 September 12–14

baltimoreConvention Center

baltimore, maryland

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• examine 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• explore the realities of delivering healthcare beyond clinical issues such as

wound clinic office politics and the finances of wound care• provide optimal healthcare delivery through improved understanding of

sites of service and payment schema

aCC reditation informationin 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 education, LLC (n ACCme), designates this live activity for a maximum of 16 AMA PRA Category 1 Credits™. physicians 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. provider approved by the California Board of r egistered n ursing, provider n umber 13255 for 16.0 contact hours.podiatrists: n orth American Center for Continuing medical education, LLC (n ACCme), is approved by the Council on podiatric medical education 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 provider #hm 001 Level 3 s ynthesis Level

physical t herapists: n orth American Center for Continuing medical education, 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 pT 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 education, 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 education.ada Statement: n orth American Center for Continuing medical education 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 Herein iS SUbJeCt to CHan Ge Wit Ho Ut noti Ce.

r obert Kirsner, md, phdv ice Chairman and s tiefel Laboratories professord epartment of d ermatology and Cutaneous s urgeryu niversity of miami miller s chool of medicinemiami, FL

o 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.

f or more information and a full list of sessions, please visit www.sawcfall.com.

Where Wound Care Clinicians Go For Answers

dot Weir, rn , CWon , CWSClinical Coordinator,Wound Careo sceola r egional medical CenterKissimmee, FL

Register now for incredible early bird rates and possible MVP

benefits!

top SeSSion S yo U Won’t f ind a t o t Her Wo Und Care Conferen CeS• Crisis 2012: The pandemic o f Wounds• What y ou s hould Know About d rugs That inhibit Wound h ealing• d o Wound Clinics Benefit patients?• Growth Factors And Advanced Therapies For Wounds: d oes The Fd A expect Too much?• n egative pressure Wound Therapy: d o The d ata s uck?• emerging Treatments For d iabetic Foot u lcers• What’s d own The p ike For v enous Leg u lcers?• Getting paid: The Finances o f Wound Care• r eality Check: What y ou s hould Know About palliative Wound Care• emerging insights o n post-Amputation r ehabilitation

endorsed by the

SAWC_FALL_2012_1-PAGE_TWC.indd 2 6/6/12 10:42 AM


patientreferrals

accept our patients. It was a bit of a com-mute, 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 de-cide that many patients could have

other services performed at his office, namely wound care. Without provoca-tion, 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 al-lowing us to follow up for wound care (after being reminded that it was much more lucrative for him to do vascu-lar 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 pa-tients 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 pa-tients 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 execu-tive 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 ResultsTWC 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.

Patient21.8%

Mutually Respectful

28.3%

Collegial 20.1%

Sporadic28.6%

Contentious6.9%

Invaluable11.8%

Nonexistent 4.3%

Patient21.8%

Provider78.2%

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

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 most culpable?



TWC newsupdateA 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

Nowokere Esemuede, MD, has ac-cepted a position at Wuesthoff Wound Care & Hyperbaric Center in Mel-bourne, 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 fam-ily 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

SPOTLIGHT ON: DIABETES Study Links Drug, Cancer Risk

New Wound Center Appoints Medical Director

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 construc-tion 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 ad-ministration is currently seeking a physician to run the facil-ity, 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 CenterCommemorates 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

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classified

SPOTLIGHT ON: DIABETESNew Treatments From Sanofi

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.

TWC newsupdate

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, [email protected] or 800-288-7762. You may also visit our website at spartanburgregional.com.

EOE

We’re looking for an experienced Wound Services Manager

RECR52A

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WCB2012WOUND 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 pay-ment policy changes for wound care, HBOT depart-ments 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/registra-tion, 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 podi-atrists, non-physician practitioners, program directors, clinical managers, therapists, billing directors, charge description master directors, HIM directors, coders, of-fice managers, corporate compliance officers, revenue integrity auditors, and hospital executives.

Early-bird and group pricing available!

Please visit www.woundclinicbusiness.com for additional information.

Friday, June 8, 2012Dallas, T exasHyatt Regency DFW

Friday, June 29, 2012Chicago, IllinoisDoubleTree O’Hare-Rosemont

Friday, September 21, 2012Cincinnati, OhioDoubletree Cincinnati Airport

Friday, October 26, 2012Baltimore, Mar ylandHilton Baltimore

Friday, November 2, 2012Anaheim, CaliforniaHilton Irvine/Orange County Airport

Friday, November 9, 2012Orlando, FloridaDoubleTree Hilton Orlando Downtown

INVESTIGATE YOUR TEAM’S WOUND CARE REVENUE CYCLE

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Advertiser’s IndexAdvanced BioHealing .............................................................................................................................. 25, 26

Darco International ....................................................................................................................................... 23

Derma Sciences ............................................................................................................................................ 15

Healthpoint Biotherapeutics ................................................................................................................. Cover 2

Intellicure Inc. .............................................................................................................................................. 11

Medela Inc ...................................................................................................................................................... 3

Net Health Systems ...................................................................................................................................... 19

Organogenesis Inc. ......................................................................................................................... 32, Cover 4

PathoGenius Laboratories .....................................................................................................................Cover 3

Progressive Wound Care Technologies ........................................................................................................... 9

Sechrist Industries Inc. ................................................................................................................................... 5

Apligraf® Essential Prescribing InformationNumbers 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 fi broblasts 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 insuffi ciency 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 Specifi c 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: 5,536,656Manufactured and distributed by: Organogenesis Inc. Canton, MA 02021REV: 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 fi le, Organogenesis Inc. 3. Apligraf® [package insert]. Canton, MA: Organogenesis Inc; 2010.

Please see complete prescribing information at www.Apligraf.com© 2011 Organogenesis Inc. All rights reserved. Printed in U.S.A. 01/11 Apligraf is a registered trademark of Novartis.

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TWC_adindex.indd 32 6/7/12 4:12 PM

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.

©2012 Healthpoint Biotherapeutics Healthpoint is a registered trademark of Healthpoint, Ltd. TM1302-0112

Potential Payment May Now Be Available for Every Application

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1004 Garfield Drive, Bldg 340 Lubbock, Texas 79416 806-771-1134 www.pathogenius.com

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

PathoGenius®

See us: WOCN Charlotte, June 10-12 Booth #1615

APMA Washington, August 16-18 Booth #2314

. . . A S C E R T A I N A S D N A !

Guided by DNA, driven by patients.™

The proprietary DecodEx® test by PathoGenius® Laboratories comprehensively

defines the wound bioburden, with DNA level certainty (including fungi).

Those ads are for Kristen Membrino, TWC and Podiatry Today

[email protected]>

PathoGenius_0712.indd 1 6/6/12 5:16 PM

Healing Wounds.Healing Lives.

Please see accompanying essential prescribing information, or visit www.Apligraf.com for complete prescribing information

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 signifi cantly improve the speed of healing and incidence of complete wound closure in DFUs and VLUs1-3

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

For information on support programs and tools available from Organogenesis Inc., call 1.888.HEAL.2.DAY (1.888.432.5232—Option 3)

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Documents

June/July 2012