Facility in Focus: Creating a Collaborative Wound Care Continuum

  Bryn Mawr, PA — Give her 90 days, and Sharon Lynn Hannum, RN, will tell you she can devise, design, and launch a hospital-based outpatient wound care center from the ground up. Give her nine months, as did the administration at Main Line Health, one of suburban Philadelphia’s most comprehensive hospital networks, and you get what you bargain for — the foundation for a program that is systematically revamping the structure and delivery of wound care across the entire health system.   Recruited to the Main Line’s Bryn Mawr (PA) Hospital in 2003 to establish an outpatient wound-healing center at the Magnet facility to target a local patient population predominantly being treated in the primary care arena, Hannum’s center has met this accomplishment and then some. With a progressively increasing patient caseload that has been on the incline since the doors opened (the center recorded 3,000 visits in 2012), the wound care program has also proven cost-effective through the establishment of a structured protocol that has since begun to be implemented throughout the hospital system’s reach along Philly’s western suburbs into Paoli (PA) Hospital. Predicated on a philosophy that utilizes a multidisciplinary wound care staff jointly trained on a collaborative procedural approach that allows consistent patient care, product usage, and electronic health record (EHR) optimization within multiple facility sites, the program, as it nears full integration, also allows patients to experience the same clinical and follow-up services provided by the same healthcare staff within the network — regardless of where they receive care.    “It’s a superior patient experience,” said Hannum, a wound care nurse of nearly 20 years with an extensive background in formulating and operating outpatient hospital wound departments along the metro regions of Philadelphia, New Jersey, and New York. “I honestly think we have one of the best functioning wound care programs available in the Philadelphia region.”   As she and her staff members attest, it’s a program born out of a collaborative effort to remain comprehensive in care, reliant on the support of the interdisciplinary staff, dedicated to providing education and follow-up communication with primary clinicians, and committed to the processes put into place. It’s also the result of a meticulous approach to wound care that’s apparent even to the extent of how the Bryn Mawr center was originally mapped.

A Collaborative Blueprint

  Laying out the plans for what would eventually become a 3,600-square-foot outpatient center took the intricate consideration of determining where entrances and exits should appear to allocating for an appropriate number of examination rooms and having the foresight to allot enough space for what would become a busy hyperbarics suite (which averages 3-4 patients per week today), all of which Hannum played a role in. With additional time afforded to the opening of the wound center as the hospital awaited the relocation of a breast health center that had occupied the wound center’s future space, Hannum had that much more opportunity to “get her hands dirty.”    “We knew we would need enough exam rooms so that patients wouldn’t have to wait long in our reception area,” she said. “It’s one thing to wait in a lobby, it’s another thing to have the access to your own room to wait. If you only have two exam rooms to offer and you have four people scheduled in an hour’s time, somebody’s going to be waiting at reception for a while. I wanted to make sure we designed a center that considered patient flow.”   With five exam rooms available (four for ambulatory patients, one that’s big enough to house a stretcher), Bryn Mawr was also designed to have the capacity to handle non-ambulatory and non-emergency cases.    “One of the most important decisions we made when we designed our center was to provide space for stretchers to come in through a back entrance that leads right into our biggest exam room,” Hannum said. “You might have someone come in with a sacral or hip wound where they can’t be in a normal exam chair, so having a bed and having the ability to open the back door so stretchers don’t have to come through the waiting room, where we often have obstacles like people in wheelchairs or on crutches, makes things that much more convenient for the patients and the staff.”   Another crucial logistical step taken during the design phase was reserving space for dressing rooms for hyperbarics patients. Originally operating with one chamber, the center added a second (bariatric) chamber six months after opening, an upgrade Hannum said she anticipated but needed the patient visit numbers to prove themselves in order to justify the acquisition.    “Knowing the amount of square footage we would need to fit enough exam rooms and a hyperbaric area was very important,” Hannum continued. “You need to know where your equipment is going before you get it. You need to know where your furniture is going. Knowing we wanted to have more than one hyperbaric chamber, we needed enough clothing rooms so that patients could come in and change in privacy while we still had patients in the chambers.”   Also not to be neglected was Hannum’s vision of the appropriate wound care staff, which includes a panel of eight physicians from a multitude of specialties including podiatry, general surgery, internal medicine, plastics, and vascular care as well as a nursing staff that today has grown to seven members among the Bryn Mawr and Paoli centers.   One of the first clinicians to volunteer for a position within the outpatient center was Daniel Westawski, MD, FACS, a plastic surgeon who had already been on staff in Bryn Mawr’s inpatient wound department at the time the outpatient center began construction. Though he stands by the wound care that had traditionally been performed at the hospital, Westawski, who also owns three private practices within the outlying region, admits that the need for a devoted outpatient center was real and that the challenge to give patients the dedicated, specialized care they deserved had become too daunting.    “Before the outpatient center opened, everyone, including internal medicine and general surgeons, would try to manage wounds on their own,” he related. “They’d call in plastic surgeons like myself to assist, but that was hard to do from a private practice standpoint because wound patients specifically require a lot of care and follow up. They require a lot of medical resources and a lot of time that, in private practice — no matter the specialty — you’re just not typically equipped to do to the degree you need to.”   However, securing the trust of area physicians to send their patients into the Bryn Mawr center would not be as easy as anticipated.

Reliance on Referrals

  Although the outpatient center had patients essentially waiting in the wings due to referrals coming from its own physician staff members such as Westawski and Robert C. Floros, DPM, a podiatrist who also owns multiple private practices in the region who previously worked with Hannum prior to joining Bryn Mawr in 2003, establishing a reputation as a referral center would take some time as well as a delicate political approach.    “Even when considering that making referrals would be a way to defray costs for primary providers and that many of them don’t have the staff to handle wound care patients coming into their offices on a weekly basis or the inventory of supplies required to manage chronic wounds, some of the area physicians were a little leery of us at the beginning — they didn’t want to ‘lose’ their patients to us,” Hannum said.   As a referring physician himself, Westawski said earning the physicians’ trust and their referrals came down to initiating communication with each provider to inform them about the structure and benefits of their services as well as their intentions to keep an open line of communication regarding all aspects of wound care that could impact other comorbidities.    “And by doing that we’ve been very well received in our community,” Westawski said. “The providers are happy to work with us as a team because we make sure we collaborate with them frequently by asking for their help in managing the patients’ overall health, particularly related to diabetes, congestive heart failure, or chronic renal deficiencies, while we’re trying to get their wound closed. Even before something as simple as a lymphedema pump, we’ll check with the patient’s cardiologist to make sure it’s not going to cause unforeseen stress on their heart. These physicians don’t want their patients needing more healing time than necessary. And we have a coordinated team of clinicians that referring physicians know have the time to devote to their patients.”

Coordinated Collaboration

  That team, aside from being comprised of specialists who represent a wide range across the healthcare spectrum, is know for the depths of experience that it collectively possesses, especially as it pertains to wound care. Floros, a fellow of the American College of Foot and Ankle Surgeons who has spent nearly 30 years in podiatric practice, has been providing wound care, as he puts it, “since before it became popular.”    “In our field of foot and ankle reconstruction, we’ve been providing wound care since day one,” said Floros, who’s spent the last 20 years of his career specializing in wound care. “I refer my patients here directly. The excellence and quality of the care here is something that I’ve never seen in my 28 years of experience. It’s just tremendous.”   Like Westawski, Floros assisted in the opening of the Bryn Mawr center, up to and including his involvement in the ordering of supplies and equipment. With his surgical background, he’s often brought in to consult on any wound below the knee, which makes up an estimated 60 percent of the program’s population. He said the collaboration between physicians and nurses begins prior to the initiation of any care planning.    “We’ll talk amongst each other about the diagnosis of the systemic disease that might be causing the wound or the trauma that might have caused it, and deal with the ramifications of that — whether it’s malignment, or the need for fusion or debridement and wound healing, or helping with referrals and establishing the network and team concept with the vascular specialist, neurologist, plastics, internal medicine or renal,” Floros said. “After a patient has been examined and we’ve determined as a team the diagnosis and reason for their wound, we’ll plug them into the specialties they need. There’s a lot of referral in the system, and the collaboration between our center and other specialists has really helped our patients tremendously as far as exponentially improving healing rates and the success rate in reducing amputations. It’s a nice luxury for patients to have in the system.”   Beyond open communication, the staff utilizes an EHR system that was implemented in 2012 and has become uniform within multiple Main Line locations. Based on the progress experienced at Bryn Mawr, Hannum was approached by health system administration to oversee the wound care program at Paoli.    “It was a great opportunity for me to foster collaboration, peer review, and coverage amongst both sites,” said Hannum, referring to a peer-review process she enacted at both sites that helps ensure protocol is carried out consistently at all times — even to the point that registration remains accurate and that all pertinent patient information is collected prior to clinical assessment. “We took what was working at Bryn Mawr and came to Paoli with it, and we began to realize that we’re not just silos in a system — we’re a proven wound-healing and hyperbaric program that’s expanding throughout the system.”   The enhanced service at the Paoli site have long been realized, according to Pamela Beideman, RN, a wound care nurse on staff at Paoli who has been with the hospital 28 years (the last seven specifically in wound care). While correlation has always existed between the two centers, Beideman said the impact of the official merger has been significant.    “It’s more uniform today — we utilize staff between the two units and coordinate our educational programs, patient care, and products being used,” said Beideman, whose extensive healthcare background includes med/surg, oncology, gastrointestinal, outpatient surgery, endoscopy, and critical care. “There’s more continuity between the units, so patients are able to have a more pleasant experience if they need to visit both locations.”   Not only has the ability for patients to undergo care simultaneously become a possibility, it has become reality for many patients within the system, Beideman said.    “We encourage our patients to accommodate whatever their schedules may be by receiving treatment at multiple centers so that there’s no break in their treatment,” she said.

Future Expansion

  In preparation for the wound care program’s expansion across Main Line Health, Hannum has started forming an affinity wound care group that’s responsible for meeting regularly to evaluate products, policies, and procedures as expansion progresses.    “If you’re not collaborating, you’re missing out on the sharing of ideas, sharing of supplies — just the general cohesion of policies, protocol, and patient care,” Hannum said. “For the patient’s peace of mind and potential for better outcomes — it just makes more sense. Our patients can feel confident and comfortable that there’s always someone here to care for them who has the knowledge and information related to their care in particular.” Joe Darrah is managing editor of Today’s Wound Clinic. (View a slideshow of the wound center and its employees here: https://www.todayswoundclinic.com/slideshow/facility-focus-creating-collaborative-wound-care-continuum)

Undergoing Wound Care, Together

Some “serendipitous” healthcare complications lead one Philadelphia-area couple into neighboring hyperbaric chambers. By Joe Darrah   Bryn Mawr, PA — Since the day they met more than 60 years ago, the lives of Augustus Michael (Gus) and Lee Iatesta have, quite literally, been defined by coincidence. Recently, so too has their healthcare.   It was the spring of 1952 when Lee was approached by her parents about a young doctor, the son of a couple they knew through a local Sons of Italy club based in the Philadelphia suburbs, whom they wanted to introduce her to. Already dating someone at the time, Lee wasn’t interested in being set up, so she shrugged it off. Unbeknownst to Gus, who just so happened to make an appearance at a Sons of Italy dance on an otherwise uneventful Friday night for he and a few friends that Lee was also at, he’d end up introducing himself upon his arrival, asking her for a dance. She obliged, and by the time Lee’s parents put one and one together for her later that evening, she was already smitten.    “It was just so coincidental that we met on our own like that, but the rest is history, because I ended up taking him to my junior and senior proms, and we married two years later,” said Lee, who recently completed several weeks of hyperbaric therapy at Bryn Mawr (PA) Hospital’s Wound Healing Center due to a compromised bladder following radiation treatment for cervical cancer. Having been previously recommended for hyperbaric treatments by his urologist a few years prior after developing minor radiation proctitis as a side effect to prostate cancer treatments, Gus had been hesitant about undergoing the therapy. With the proctitis condition doing little to impact his quality of life, he had decided against hyperbarics because of the weeks-long commitment he was told it would take to achieve full wound closure. However, when Lee was informed that hyperbarics was the only option she had to close a hole in her bladder that registered the size of a half dollar, Gus began to see the procedure in a new light.    “I figured, if my wife had to do it and I could benefit from it, we might as well do it together,” he said. After more than two months of treatment sessions, both are fully healed.

Road to Recovery

  Prior to the hyperbaric treatments, Lee’s condition had become very severe. Saddled with catheters on each kidney, her bladder would not function on its own and life had become very painful, not to mention uncomfortable. She underwent surgery in an attempt to repair her damaged bladder, but due to her age and radiation treatments, the bladder wall had become too thin to seal. Sensing how fearful Lee had become from the multiple procedures and the lengthy hyperbaric regimen she would need to undergo, Gus didn’t want her to go through anything alone. They were both relieved to learn that the wound care center at Bryn Mawr, less than a 20-minute commute from their home in Broomall, PA, could not only treat them both but allow them to do so side-by-side in neighboring chambers. For more than two months the couple spent the middle of their afternoons together in the wound center. Though Lee’s 40 prescribed treatments outnumbered Gus’ required 35, he’d accompany her through the duration of her visits — often spending some downtime getting to know their caregivers better.    “It was one of those serendipitous things that you can’t say you ‘enjoyed’ doing, but it was nice to be able to support each other,” said Gus, a retired optometrist who also underwent open-heart surgery this past July for an aortic valve replacement and two bypasses (as well as the subsequent cardiac rehabilitation, which frequently overlapped with his hyperbaric therapy). “The care we received exceeded our expectations. We got to know all the physicians and all the staff, and everyone was very courteous — we had absolutely a completely positive experience.”   The couple know a bit about serendipity. Aside from how they met, their daughter met her husband, a Frenchman, while working at a convention in New Orleans several years ago. She, a manager for a company that operates national medical conventions and he, an engineer who was visiting the US in hopes of securing a research grant, didn’t have much time to get acquainted before he had to return home. However, when that grant ultimately came through from Philadelphia’s Drexel University, the two had a chance to reconnect. Today, they’re married, living in France, and the Iatestas can say they have five bilingual grandchildren.    “After the initial shock of her moving,” Lee said, “I told myself she could just as easily have met someone from Iowa or Illinois and moved there; but I’d much rather land in Paris and see the Eiffel Tower when I go to visit her.”   With their health back on the mend, frequent travel has again become part of life for the Iatestas, whose regular travels have also seen them visit Italy, Spain, Sardinia, the Caribbean Islands, China, Singapore, and Iceland. Speaking with Today’s Wound Clinic on the heels of Lee’s most recent urologist visit in early March, the couple was ready to celebrate her recent clean bill of health. Their plans for spring included an annual trip to Florida, where they’ll spend several weeks enjoying each other’s company, relaxing, and maybe taking in a movie or two together outside the confines of a hyperbaric chamber.    “It’s been a tough year, health-wise,” Gus said. “Hopefully, we’ll have some time out of the hospital now for a while.”

A Global Wound Care Perspective

Forced into permanent US residency due to civil unrest back home, an Iranian physician joins the wound care ‘revolution.’ By Joe Darrah   Bryn Mawr, PA — Upon leaving his native Persia for the US in the mid-1970s, Manoucher Afshari, MD, FICS, FACS, had his career, his life all mapped out. Having already earned his professional doctorate in medicine, he wanted to do the same in the US and bring that knowledge and skills back home.   But as he finished his education at the turn of the new decade, the Iranian Revolution was in full swing — political and social unrest posing threats to safety. At the urging of his family, he decided to “keep his distance for a few months.” Twenty-three years later, he’s still here, carving out an extensive healthcare career that recently led him into wound care, which has also seen great change in the time since Afshari entered this country.    “After about three years went by and home was still the same with chaos, I had to look around at my children growing and realize that this is where me and my family were staying,” said Afshari, one of eight physicians at Bryn Mawr (PA) Hospital’s Wound Healing Center. “I am very thankful and fortunate to be here still.”   Putting off random urges to retire over the years, he’s proven to be an asset to the outpatient wound program at Bryn Mawr due to an extensive healthcare background that he said greatly lends to the care of his patients.   A member of the Bryn Mawr staff since October, Afshari spent more than eight years in residency during the 1980s, including general surgery, trauma surgery, cardiac surgery, and kidney transplant surgery. In order to maintain a valid visa during this time, Afshari said he had to remain “in training,” so he kept broadening his scope of practice.    “At that point I was determined to stay in the United Sates and learn as much as I could, even if that meant that I would ‘retire’ one day as a resident,” he said, somewhat in jest. “I came to the US because I wanted to be a surgeon, and this was and still is the best place to learn how to practice medicine.”   At the age of 40 in 1982, he opened his own general and vascular surgery practice while working as a trauma surgeon. He’d do so for 10 years before relocating north to Maine in the early 2000s during a time in Pennsylvania when many physicians closed or relocated their practices due to high insurance costs. Further expanding on his skills in the “Pine Tree State,” Afshari spent eight years practicing as a general surgeon in a rural, 15-bed hospital. The more patients he began to care for who lived with chronic, nonhealing wounds, the more his interest in specializing in this field became piqued.   Today, he’s a fellow of the American and International College of Surgeons and serves as clinical associate professor at Temple University in Philadelphia, where he instructs residents and medical students. His curriculum includes wound care, which he said he continues to gain an increased appreciation for.    “In general surgery, you know certain physiology of wounds but you don’t always realize how much a wound center can help your patients heal their wounds,” he explained. “When you’re talking about patients who’ve had wounds for many years, something’s missing in their overall care and their health. So I’ve tried to bring my expertise and combine it with treatments that we use in the wound center to help our patients heal.”

Here To Stay

  At Bryn Mawr, Afshari works among an interdisciplinary physician and nursing wound care staff that includes podiatry, general surgery, internal medicine, plastics, and vascular care.   Through a care philosophy that stresses collaboration and a uniform protocol that has been clearly defined and implemented into a universal electronic health record, Afshari and his colleagues are changing the way wound care is conducted for many people living in Philadelphia and its surrounding suburbs.   Launched in 2003, the wound-healing program at Bryn Mawr has since extended into the company’s Paoli (PA) Hospital. Afshari said the collaboration within the wound program serves as the basis for the improved wound healing and amputation rates that the network is seeing.    “There’s harmony in this system; we work together — that’s the only way to do it,” he said. “A lot of hospitals today want to open their own wound centers, but you have to be willing to standardize your care and hold yourself to a very high standard.”    “At the start of my career, there were no wound centers,” he continued. “But wounds have always been ‘wounds’ — whether they’re due to diabetes, atherosclerosis, infection, trauma, war, whatever. The only thing different today is the way that we treat them. We understand more of the philosophy behind what heals wounds and how to better care for patients.”