Taking a Multidisciplinary Approach to Care at Denver Wound Healing Center

During our trip to SAWC Spring 2013, Today’s Wound Clinic visited the Denver Wound Healing Center at Presbyterian/St. Luke’s Medical Center, where we met not only many of the clinic’s staff members but three of their most inspiring patients. Our photo slideshow provides readers with a glimpse of whom we met and the types of chronic wounds they're living with. View the slideshow here: https://www.todayswoundclinic.com/slideshow/photo-slideshow-taking-multidisciplinary-approach-care-denver-wound-healing-center   Denver, CO — There were many justifiable reasons to think that Dian Clawson’s wound might never fully heal. More than two months had already passed since her triple bypass surgery when the 74-year-old presented at Denver Wound Healing Center last spring with an infection at the site of the saphenous vein harvesting required for her heart procedure. Measuring 16.5 cm long, 2 cm wide, and 0.5 cm deep, the wound practically ran the length of her left leg. Although she had already received several weeks of negative pressure wound therapy (NPWT), Clawson was afforded very little in the form of guarantees when a quantitative culture taken during her initial assessment revealed MRSA. If the overall severity of the wound didn’t pose enough of a challenge to close, Clawson’s condition was further complicated by a steroid dependency that developed due to her long-term treatment of Addison’s disease, a condition the Centennial, CO, resident has lived with more than 30 years that’s also led to type 2 diabetes. Between her age, chronic comorbidities, and immunosuppression, it would be daunting to even attempt to consider ranking the severity of each treatment hurdle from a wound care perspective, said Debra Stanley, RN, a staff nurse at the clinic — a comprehensive, multidisciplinary facility housed in Presbyterian/St. Luke’s Medical Center — and the primary nurse assigned to assist Clawson’s wound care planning.    “She presented as a very tricky case because there were a lot of puzzle pieces that led her to be a very high risk for infection,” said Stanley, who characterized the wound as one of the most severe that she’s seen. “She’s steroid dependent, she’s diabetic, she was deconditioned physically following her bypass surgery and required a rehab nursing home stay prior to visiting us, there was already an infection to be addressed, and the wound bed wasn’t even ready yet for the placement of the vac [which had been placed previously by another facility],” Stanley continued. “She presented with a difficult problem for our team to solve, for sure.”   Solve it, they did. But not before Clawson, one of three uniquely complex patients at the clinic who recently met with Today’s Wound Clinic during on-site interviews, developed an unrelated case of pneumonia as well as a recurrent case of MRSA. Clawson has since fully recovered, but just as is the case for the other individuals who were willing to share their experiences with TWC, her story is her journey to healing — the common thread being each patient’s path to this wound center — which opened more than 20 years ago as the first specialized wound care clinic in the Denver metro region and today stands as the largest of its kind in the state, offering the services and expertise of more than 12 specialty-certified physicians specializing in general, plastic, and vascular surgery; internal medicine; podiatry; and hyperbaric medicine.

Serving An Unmet Need

  At the time Presbyterian/St. Luke’s began operating its wound clinic in 1991, there was a significant lack of comprehensive wound care services available to area residents, who up until that time were relying on inpatient hospital settings and, more likely, private physician practices to conduct their wound treatments. Essentially, there was a groundswell of patients waiting for better quality of wound care from the time the facility opened its doors.    “And that’s not to say the clinicians around here didn’t ‘care’ about their patients or that they weren’t providing for them — it was about them not having availability of the appropriate tools that this patient population needs or the time to devote to them,” said Paula Stanton, PT, CWS, MBA, manager of the Denver Wound Healing Center and its accompanying Diabetes Management Center. “There was an unmet need for dedicated wound care services in this region. And we offer a program that’s multidisciplinary and multifaceted — which is what most wounds are. Most patients aren’t going to ‘just have’ a diabetic foot wound. They will also have venous insufficiency, congestive heart failure, and so on.”   Case in point: Clawson, who, prior to her arrival to the clinic, had received wound treatment while undergoing post-surgical rehabilitation in a skilled-nursing facility. By the time she was referred to the Denver Wound Healing Center, both she and her husband Alden were physically and emotionally worn down from her experience, which began in March 2012 with the heart surgery.    “We had some adverse feelings about the care she had received up until then and with what we were dealing with overall,” said Alden. “It was a very stressful and difficult situation.”   Given Clawson’s health and the gravity of her complications, the wound clinic staff would suggest a care plan that required her to revert back to “square one” as per its standard of care and general algorithms. Spending more time to seek out a means to healing was all anyone at the clinic could really assure, which, in reality, is all they can promise any patient. (Though, they boast a 16-week, 88.6% healing rate.) But for those patients like Clawson who are living with chronic, complicated wounds that haven’t received the treatment they require and have experienced similar situations in which other providers haven’t been able to give them the answers and hope they’re seeking, the individualized attention, education, and care planning they receive at the clinic is in some ways a cure in and of itself. Consider Jesse Davila and Mary Crooks, two additional clinic patients who met with TWC during our recent trip who’ve had their own circumstances and wounds that have persisted over the last several years.

Devoted to Diabetes

  Davila, also a diabetic, is married with three children and was diagnosed with type 2 diabetes in 1999 — on the same day as his father, in fact, in an ironic twist of healthcare fate. However, he believes that he was never appropriately educated about his disease until he was introduced to the wound clinic of his own volition this past fall, when he asked his primary physician for a new wound care referral because he had become fearful that he was not getting the care he needed at another facility. Having lost his right foot to an amputation due to Charcot joint in 2006, Davila, 55, said he decided to switch wound care providers when he was given a “we will eventually have to amputate” assessment for and had been given several debridements.    “They were just debriding, and debriding, and debriding — it was like déjà vu with what happened the first time I had a foot ulcer, and I knew things weren’t going to get better when they told me they ‘didn’t know what else to do,’” said Davila, a Texas native who moved to the Denver region in 1993 after “falling in love” with the area while on vacation. “When they told me that, I knew I had to get out of there, because it was like my foot was just being whittled away.”   A resident of Broomfield, CO, Davila said the nearly 50-mile, one-way drive he makes to the clinic is barely noticeable when weighing the benefits of the care and education he has received. As a patient in the Diabetes Management Center, he has received weeks of one-on-one consultation with an endocrine and diabetes specialist as well as education sessions with his wife Joanne, who has also been trained to assess and manage drainage of his wound and help the clinic staff evaluate how often he needs to be seen. Weekly visits have since been reduced to twice per month with the self-care management Davila has been taught.    “We know that he’s educated enough that we can rely on him to monitor his condition at home instead of dragging him into the clinic every week,” said Jodie Royer, RN, Davila’s primary nurse. Jesse wants to keep his foot and he’s been willing to do what he can to help us see if we can do that.”   Davila, whose ulcer measured 2.6 cm x 4.5 cm when he first presented and 0.3 cm x 0.5 cm at the time of the TWC visit, insists that his willingness to properly self-manage his care has always been there, but that he went years without getting the formal education required to do so. As he sees it, had he been better educated from day one, he may not have lost his right foot or needed a kidney transplant, which occurred in 2008 and landed him an extended hospital stay when MRSA developed after surgery.    “I needed to learn how to manage my diabetes,” he said. “Like a lot of people, if you’re not educated, you think that the only thing you have to do is give yourself an insulin injection when your numbers don’t look right. But you’re just masking the problem with the insulin if you’re not taking care of yourself through dieting. I know now that when you get an infection as a diabetic that you have a lot of problems controlling your sugars.”   When he was first assessed at the wound clinic, his hemoglobin A1c was at 7.9 but has since been reduced to close to 6.    “It’s not exactly where we want it, but it’s closer to what we’re looking for than before he came in,” said Royer. “Because Jesse needs to be monitored closely following his transplant, we’ve discussed that he needs to keep his sugars in check if he wants us to turn everything that we can do for him into wound healing. There’s no telling how long the underlying infection has existed, but I think the biggest thing lacking in his previous care was that it seems nobody conducted a quant culture, which allowed us to give him the PO antibiotics, because it showed positive for bacteria, and move forward systemically. Or, it might be that the wound previously was being cleaned too much. There’s a fine balance between cleaning too much because you can lose too much granulation tissue there.”   Once confined to a wheelchair, Davila now ambulates with the help of a prosthetic and is able to remain active with his kids. He credits the wound clinic and his care providers for that.    “I’m not an indoor, watch-TV type of guy,” he said. “From the time I got here I’ve been learning and seeing my infection being treated and improving. If I didn’t come here I don’t know if my infection would be addressed.”   Mary Crooks, a patient in the clinic who’s being treated for a rare skin condition, can relate to exactly that sentiment. Forced into an early retirement due to a chronic case of sporotrichosis (commonly referred to as rose-picker’s disease), Crooks, 71, went undiagnosed with the ailment for nearly two years, seeing multiple dermatologists and infectious disease specialists, before she was referred to the wound clinic in spring 2011. But the depths to her declining health run decades long and actually started with a dental procedure.

Treating Rare of Infections

  It was 1995 when Crooks had what was thought to be an otherwise routine root canal procedure. In the ensuing days, however, she developed an abscess on her chin that formed a draining sinus that required surgery to remove. The surgery seemed successful, but an undiagnosed case of actinomycosis persisted and migrated to the left side of her face — where multiple, painful fistulas developed that she unsuccessfully attempted to cover up with Band-Aids and makeup. By the time she received the correct diagnosis about four years later, there was little that the oral and IV penicillin could do to repair the damage beyond eliminating the actual bacteria, and plastic surgery was needed — which include grafting and partial removal of her face. … And that’s still not where her problems ended.   Enter the sporotrichosis. “Shorty after the plastic surgery procedure, I was out picking flowers with my granddaughter out front of my house, and let her wear my gloves because she didn’t have any and her hands were getting dirty,” Crooks related. “My niece was getting engaged and we thought the flowers would be a nice gift for her. It was just so innocent — and the worst part of it is, I don’t even like gardening.”   Immunocompromised due to her prior infection, Crooks was vulnerable to the sporotrichosis, which is caused by a fungus that lives in soil, plants, and decaying vegetation. The infection would eventually spread from her fingers and up both arms in the form of painful, raised ulcers.    “I went to a variety of doctors and specialists and had been from clinic to clinic,” said Crooks, adding that many providers suggested she was experiencing Munchausen syndrome, a mental health disorder characterized by self-infliction of wounds and delusions of being ill. In all, she estimates living with the sporotrichosis infection eight years and would end her career as the senior vice president of a local financial services company early to “commit full time” to locating someone who could find her a cure.    “I had a career that I really enjoyed and continued to work as long as I could, but it just became too much to deal with,” she continued. “I also have five grandchildren, and I didn’t want them to think of me as an invalid. By the time I got here, I was in so much pain and was so demoralized and depressed with my history that I needed to be in a wheelchair. I hate to think it, but I was beginning to give up hope.”   Though Crooks said she had been adamant with every provider she met about sporotrichosis after reading about its symptoms online, it was often dismissed until she found the wound clinic — on a dermatologist’s referral.    “We see a lot of unusual wounds here, and we have the forte from experience to identify them and deal with them,” Stanton said.   Cared for by Robert Carson, MD, board-certified in internal medicine, Crooks received a high dose of Sporanox and intravenous immunoglobulin (IVIG). Results came gradually, but were evident. Her husband Bob was also a driving force of support the entire time.    “Mary had a very long and involved wound history, so she’s had a couple of underlying problems that’s affected things, but the IVIG really helped her turn the corner,” Stanton continued. “And with the volume of patients we see, we’re bound to see a variety of conditions. We go through our standards of practice by addressing compression, circulation, and infection — and if something isn’t working as well as we’d like, we can actually look back on other cases that we’ve seen. It’s very helpful to be able to see enough patients that your memory can be triggered by particular patients and particular wounds.”

Just Your Basic “Gold” Standards

  And then there’s Clawson, whose case actually led the clinic to investigate a plan of care borrowed from evidence-based practice. Upon her initial assessment, Bryan Kramer, MD, FACS, one of four board-certified vascular surgeons at the clinic, ordered a quantitative tissue biopsy/culture, which has generally become accepted as the “gold standard” for evaluating the presence of microorganisms. Clawson’s NPWT was immediately discontinued, as it was deemed to have been applied to the wound bed prematurely.    “We basically took five steps backward in order to move forward with her because we needed to get the wound bed ready to respond to the wound vac through debridement and get the wound cleaned out,” Stanley said. “We just wanted to pay attention to our algorithms, which is to design a treatment plan to care that’s unique to the wound and etiology.”   Clawson was placed on a bleach-based Anasept gel and scheduled for sharp debridement; however, conditions would be further hindered when she was diagnosed with pneumonia soon after her first visit, which landed her back in a hospital, stalled debridement for two weeks, and kept her out of the wound clinic for nearly another month. Upon her return in late June, she was placed in single-layer compression and had NPWT reinserted. By mid-August the wound had shown significant improvement with a measurement of 13.6 cm x 1.9 cm x 0.02 cm, but would suddenly stall and show no signs of further improvement over her next two visits, prompting another culture that revealed the re-emergence of MRSA. Admittedly, the staff was puzzled.    “We weren’t sure why the MRSA returned — we just know it’s something that is a serious problem for hospitals and in the community setting everywhere,” Stanley said. “And we knew that since she was so fragile with her overall health that we needed to pull together as a team to decide how we might mange her care better and think of ways to decolonize her.”   An investigation into evidence-based practices turned up interesting results from a study released in 2012 conducted by HCA Healthcare that showed a 44% reduction in MRSA and other bloodstream infections among ICU patients who are universally decolonized.    “The study interested us because it used a topical agent,” said Stanley, referring to a chlorhexidine antiseptic soap, that when combined with the swabbing of patients’ noses with mupirocin ointment, specifically reduced the number of individuals harboring the antibiotic-resistant bacteria by 37%. The success seen by Clawson was quickly apparent, Stanley said. “Because we were willing to dig a little deeper and use the study as a framework, we were able to eradicate it completely and heal the wound,” she continued, adding that a focus on education also contributed. “Not only did we teach Alden and Dian how to deal with MRSA in the home, we taught the home-care services staff to be our eyes and ears in the home. But we knew what we were trying was evidence-based, and everyone was striving for the same goal.” Joe Darrah is managing editor of Today’s Wound Clinic.

Belief in Healing ‘All Wounds’

By Joe Darrah   When Paul Thombs, MD, frankly explains, “all wounds are supposed to heal,” he’s not just trying to state the obvious. And he’s hardly passing off a grand generalization that requires no burden of proof. No, when he says that he expects each wound treated at the Denver Wound Healing Center at Presbyterian/St. Luke’s Medical Center to heal, he means it — albeit soft-spokenly.    “People are supposed to heal — we’re genetically encoded to heal — so, when a wound is not healing it’s because something is wrong in that process,” said the board-certified hyperbaric physician, one of more than 12 specialty-certified physicians at the clinic, for which he once served as one the founding medical directors when it opened in 1991. “And the key to getting people to heal is understanding what is wrong, why they’re not healing, and how many different issues there are that are keeping them from healing.”   At the wound clinic, that understanding is nurtured by a multidiscipline approach to care.    “Every patient receives an in-depth nursing and physician assessment, and we start laying out a plan depending on their condition, their history, and the resources that they’ll need in order to heal,” he explained. “If it’s someone whose diabetes is not being well treated, we’ll bring in our diabetes educator. If it’s someone we know is going to need reconstructive surgery or there’s a vascular problem that clearly needs a closer look, we’ll get the plastic or vascular surgeon involved. Our protocol allows all the physicians here to easily refer to one of our other clinicians, and that’s where the nursing overlap also helps because they work with all the physicians and can be pulled into particular cases based on the experiences they’ve had with patients and physicians over the years.”   As part of the multidisciplinary-care model, clinic nurses serve as case managers who serve as primary wound care nurses for each physician and patient while coordinating care with other specialists and with patients throughout the course of treatment.   The model has proven its worth in producing an overall healing rate of 88.6%.   But does that lead to facing expectations that can be difficult to meet?    “That’s not so much a challenge as it is an opportunity,” Thombs said. “A patient who has a chronic wound and wants to do something about it — we have a lot of tools in the toolbox for them. What else could you ask for as a provider?”

Revamping Neonatal Wound Care

By Joe Darrah   This summer, the Rocky Mountain Hospital for Children at Presbyterian/St. Luke’s Medical Center, Denver, CO, strengthened its impact on the field of pediatric wound care with the expansion of its NICU. With an ever-increasing caseload of newborns requiring wound care services, the upgrade was needed not just to meet the demands of a patient population that spans a seven-state region — and travels from as far as Wyoming and New Mexico to be cared for by the renown pediatric referral center — but to foster an environment that’s expected to produce industry-breaking evidence-based research and practice. Though they haven’t had much time to get acquainted with their new space, which opened July 10 and has now grown to 84 beds, the NICU’s nurses who comprise its “skin care committee” are undertaking a study that will consider optimal skin care treatments for premature infants. Patricia Thewes, RNC, expects their results will be of great use to hospitals across the nation.    “Our unit wants to be on the cutting edge — to be a leader in this area,” said Thewes, a NICU nurse who helped create the unit’s skin care committee, which includes nine nurses (including managers) who meet regularly to discuss possible changes to unit policies and procedures and review evidence-based research findings that could support patient protocols.    “I’m really proud of our team and the backup that we have from our nurse practitioners and neonatologists,” said Thewes, who’s also a member of the hospital’s pressure ulcer team that each quarter examines all NICU babies at risk for pressure ulcers due to their size and inability to reposition themselves. Also, with the “mile high” altitude, many newborns are high risk for skin breakdown on their nares, ears, coccyx, and occipital area because of limited positioning. A nurse with nearly 20 years of wound care experience, Thewes has also been instrumental in the development and re-writing of overall skin care in the NICU over the last six years, such as protocols and timelines for dressings, when ostomies should be changed, and troubleshooting with G-tubes for skin breakdown.    “We’ve come up with a care plan sheet for ostomies, G-tubes, surgical wounds, and IV infiltrates; and the skin care team follows up with nurses who are caring for these patients to make sure protocol is being followed,” she said, adding that education plays a large role on the unit. As such, all NICU nurses are now required to attend skin care in-services from changing of nasal cannulas to dressings and new protocol. Annual competencies and skills checks are also held, as are educational sessions that provide oversight, guidance, and review of procedural steps for care planning until they’re performed correctly.    “I think we’re helping people to be more aware of how fragile the skin can be with the patients they care for,” she said. “Especially with our new grads.”