When Should We Refer A Patient To A Wound Care Center?

When should we refer a patient?

Medicine is a wonderful, varied profession covering the body from head to toe. From the internist who serves as gatekeeper and jack-of-all-trades to the specialized surgeon, the body is well cared for from head to toe. Podiatry has become specialized over the past decades to include everything from sports medicine and ankle surgery to wound care. Often, the challenge in medicine for the practitioner is to know when to refer a patient to someone with more specialized training.

A question I receive frequently from general practitioners is “Aren’t all podiatrists trained in wound care?” The vast majority of podiatrists have received some kind of training in wound care but very few have specialized in the field. With the increase of diabetes and diabetic foot problems, many wound care programs now exist and offer specialized lower extremity wound care.

Diabetes is on the rise and now affects more than 26 million Americans and more than 366 million people worldwide.^1,2 Diabetes is a pandemic problem that results in an amputation every 20 seconds and the loss of life every seven seconds.³ In the United States, diabetes is an epidemic that continues to take a large toll. In the U.S. alone, each day, 5,000 patients get a diagnosis of diabetes, 280 lose their lives and 180 lose their limbs, costing $670 million to the healthcare system.^3,4 Every five minutes, a patient will lose a limb in the U.S. due to diabetes.^3,4 With a rapid linear growth of diabetes and no signs of plateauing, early diagnosis and treatment are essential.

A Closer Look At The Special Challenges Of Wounds
Wounds are a common manifestation for patients presenting to medical offices and many podiatrists practice wound care and treat wounds in their office. Diabetic foot ulcerations (DFUs) are on the rise and people with very complicated cases literally walk into a podiatrist’s office daily. These cases can be very daunting with often critically ill patients. Malpractice claims are on the rise, particularly those involving the treatment of diabetic foot ulcers. A growing trend in many markets is referring DFUs to wound care centers. Some podiatrists, however, are hesitant to refer patients with DFUs and instead try to manage and treat them instead. These DPMs may raise the question, “Why should I refer a patient with a DFU to a wound care center?”

The overwhelming majority of podiatrists in private offices can easily manage simple wounds. However, as the complexity of the wound and the patient rise, there needs to be a moment of clarity in order to determine when to ask for help. Often, podiatrists will spend several weeks tending to a complex wound that fails to improve or actually worsens when the clinician decides to try to send the patient to a wound care center. Obviously, each practitioner will need to determine what he or she feels comfortable treating, and when he or she needs help. Clearly, this will vary from doctor to doctor. Probably the largest factor is swallowing our pride to ask for help. I try to reinforce with my referring doctors that we are on the same team helping each other and that patients are why we are in practice.

Key Insights On The Level Of Care Wound Care Centers Can Provide
Wound care centers offer a specialized level of care that is typically not available in a private office. These centers offer state of the art, specialized equipment, up-to-date techniques and an interdisciplinary team approach ideology to manage complex diabetic foot cases.⁵ This approach allows physicians to collaborate with one another for immediate care and is optimal in patients with diabetic foot infections in order to increase the likelihood of limb salvage.⁶

In addition to an interdisciplinary approach, there are a plethora of skilled services and advanced technological resources that may not be available in a private office. These resources may include hyperbaric oxygen chambers, digital thermography (LUNA Fluorescence Angiography, Novadaq), negative pressure wound therapy (NPWT) and biogenic skin graft substitutes. Being well equipped and having the latest technology, wound care centers offer the best possible outcome for the patients.

Wound care centers provide diversified techniques and technologies that range from direct wound care to hyperbaric oxygen therapy and everything in between. Hyperbaric oxygen therapy (HBOT) enables patients to breathe 100 percent oxygen with increased atmospheric pressure, resulting in oxygen saturation of their hemoglobin.⁷ With nurses and physicians who are well-trained in HBOT, this can be an option for patients to heal their wounds by increasing oxygen transport by plasma. The effects that patients may see are enhanced bacterial resistance, increased fibroblast activation, promotion of collagen synthesis, mobilization of stem/progenitor cells from the bone marrow and angiogenesis.⁸

LUNA Fluorescence Angiography is another technique that clinicians use at the wound care center to further the healing process. This enables clinicians to visualize and assess tissue perfusion and viability in diabetic foot ulcers and non-healing wounds.⁹

Other techniques and technologies used at a wound care clinic that may not be available at some private offices may consist of but are not limited to NPWT and specialized dressings. Negative pressure wound therapy involves the placement of a suction device on diabetic foot ulcers that increases the progression of granulation tissue for large chronic wounds. The use of NPWT also helps increase blood supply to the wound to facilitate healing while removing exudate and controlling infection.  

Specialized dressings can also be impactful in the treatment of diabetic foot ulcers. A myriad of available dressings can assist with moisture, exudate and bacterial control as well as the delivery of growth factors. Biogenic skin graft substitutes are beneficial since they enhance granulation and facilitate wound closure.⁹ The priorities of wound care clinics are to preserve limbs and prevent amputations by using an interdisciplinary approach and the most cutting-edge techniques.

With podiatric medical advancements, there needs to be a paradigm shift in conventional and traditional medical thinking. It is necessary to rely on wound care clinics to improve outcomes in patients with diabetic foot disorders similar to how burn victim are transferred to special burn units to heal. Therefore, since time is of the essence when it comes to tissue loss and healing, prompt intervention in patients with diabetic foot disorders may preserve limbs and restore function.⁸ Wound care centers need to be proficient havens for healthcare providers to refer patients with diabetic foot disorders so healthcare providers have confidence that their patients are in the best possible hands.

Wound care centers can have a profound impact on patient lives and economic ramifications to the healthcare system. Instituting a structured diabetic foot program can yield a 75 percent reduction in amputation rates and a nearly fourfold reduction in inpatient mortality.¹⁰ The statistics are an overwhelming endorsement for wound care centers treating patients with diabetic foot ulcers. This also has a major economic impact on the healthcare system. With each $1 invested in care by a podiatrist for people with diabetes, there is a resulting $27 to $51 of healthcare savings.¹¹ The savings invested in prevention and early treatment versus palliative symptomatic care are astronomically cost-effective. With diabetes on a historic rise, wound care centers are a necessity for patient health but also a critical requirement economically.

In Conclusion
The fight against diabetes is an uphill battle but it is a battle that is worth fighting and we can win it. Winning requires healthcare providers to work as a team, communicate among all specialties, and know when and where to refer. Patients are the priority and referring a patient with diabetes to a wound care center would be a good strategic move. Maintaining good relations with other physicians in different specialties will make this a smoother transition to accomplish a common goal. After all, the different specialties make up the sum of all parts for treating the human body from head to toe.

Dr. Espensen serves as the Co-Director of the Amputation Prevention Center and Clinical Education Coordinator at Valley Presbyterian Hospital in Van Nuys, CA. He is a Clinical Assistant Professor in Surgery at the Western University of Health Sciences in Pomona, CA.

Amy Wong is a third-year podiatric medical student currently attending the Western University of Health Sciences in Pomona, CA.

References

1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet 2011. Available at https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf .
2. International Diabetes Federation. IDF Diabetes Atlas, Fifth Edition, 2012.
3. International Diabetes Federation. Available at https://www.idf.org/worlddiabetesday/toolkit/gp/facts-figures .
4. Armstrong DG. Diabetes facts and figures. Available at https://diabeticfootonline.blogspot.com/p/diabetic-foot-facts-and-figures.html .
5. Sumpio BE, Armstrong, DG, Lavery LA, Andros G: The role of interdisciplinary team approach in the management of the diabetic foot. J Am Podiatr Med Assoc. 2010; 100(4):309-311.
6. Wukich, DK, Armstrong DG, Attinger, CE, et al. Inpatient management of diabetic foot disorders: A clinical guide. Diabetes Care. 2013; 36(9):2862-2871.
7. Latham E. Hyperbaric oxygen therapy. Medscape. Available at https://emedicine.medscape.com/article/1464149-overview#a1 .
8. Belczyk, Rogers LC, Andros G. The diabetic foot. In (Moore WA, ed.): Vascular And Endovascular Surgery: A Comprehensive Review, Eighth Edition. Saunders Elsevier, Philadelphia, 2013, pp. 59.
9. Luna Fluorescence Angiography for Wound Care (2104). Available at https://novadaq.com/products/luna-fluorescence-angiography .
10. Weck M, Slesaczeck T, Paetzold H, et al. Structured health care for subjects with diabetic foot ulcers results in a reduction of major amputation rates. Cardiovasc Diabetol. 2013; epub Mar 13.
11. Carls GS, Gibson TB, Driver VR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2011; 101(2):93-115.