Facility in Focus: Providing Wound Care in ‘Steeler Country’

  Washington, PA — Life within the industrialized Pittsburgh Metro region operates under a long-held code, an understanding among residents that has transcended generations.

  “In this area, we’re known as the ‘Steelers’ because we work hard and play hard — that’s the attitude of individuals around here, and they have a lot of pride in what they do,” said James Marks, DPM, FACFAS, FAPWCA, medical director at Washington Health System Wound & Skin Healing Center.

  It’s an attitude that goes far beyond the clichéd, stereotypical image of the steel mill worker who grew up among his hardhat-wearing brethren — the local steel industry’s collapse occurred more than 30 years ago. 

  However, a gritty work ethic remains a sense of identity among those who live and work here. And while the reputation may be admirable, it’s not one that lends to great healthcare habits.

  According to the CDC, each of the three neighboring counties that comprise the clinic’s coverage area (Fayette, Greene, and Washington) was associated with some unappealing health statistics as recently as 2008, when Fayette County was linked to the highest rate of diabetes (10.7 percent) in the state and was among 19 counties (including Washington) to have at least 30 percent of residents categorized as “obese.” Additionally, Greene County was determined to have the “least active” inhabitants while all three counties were found to have at least 10 percent of those ages 20 and older to be living with diabetes. Whether these disparities are a result of too much hard-nosed work and play interfering with time to exercise, visit one’s physician regularly, or eat healthy is up to conjecture — what’s not is the increasing rate that wound care has been needed, including for work-related injuries. (See Wound Care Patient Profile.)

  “Because of the Marcellus Shale in this region,” explained Marks, referring to a massive unit of sedimentary rock that has been found throughout parts of eastern North America that serves as a natural gas reserve, “we have a huge influx of people coming here to work and to tap into the natural resource.”

  The trickle-down effect at the clinic, which was founded six years ago by hospital officials in response to what had already been a growing number of patients who lacked an accessible, dedicated wound facility, has been an ever-increasing patient population. In 2012, the clinic’s patient volume grew by 70 percent (or roughly 23% annually) since its doors opened in 2007. The increased caseload is exactly what hospital administration and clinic staff envisioned as they developed a protocol for providing care through a nursing-focused system that stresses relationship-building.

  “We make a concentrated effort to build relationships with everyone involved so that the patient knows we’re committed to them and that caregivers, whether they be a family member or local skilled-nursing facility, visiting nurse agency, or personal care home, understand that we’re a resource and that we’ll provide the best care for their patients,” Marks said.

A Caring Commitment

  These relationships are forged immediately. When patients arrive at the facility, they are briefed by their nurse and physician on the state of their existing wounds as well as their overall health in relation to wound care, their prognosis and expected course of treatment, their timeframe for wound healing, and their responsibilities as a patient to promote wound closure and prevention.

  “The key is to ‘frontload’ the patient with information from the start of the relationship,” Marks said. “They need to know what to expect. Their time is important, and they need to know that we’re giving them 100 percent of our focus when they’re with us.”

  In keeping with the theme of the community, the majority of the clinic’s patients are the working type who depend on providers to keep them healthy enough to not just earn a living but to fund their healthcare. This is where the role of education comes squarely into play, Marks said.

  “These are tough economic times, and unfortunately we see patients who are skipping medications because they can’t afford their copays, or they’re cutting their dosage in half,” he added. As such, overall compliance remains a major concern with patients, who are brought to task by clinic staff just as much as they are kept informed, beginning at the first point of care.

  “Our patients are normally here because they have complex problems with multiple comorbidities,” said clinic manager Rita Palaisa, BSN, RN, CWOCN. “Many of them have been living with their wounds a long time, and our responsibility is to figure out why their wounds have not progressed toward healing. Regardless of what the barrier is, the best way around it is through the development of relationships.”

  Which means establishing trust and honesty, she said. For those patients with their hearts set on getting healthy and salvaging limbs because they want to live a normal life and not lose their job, their commitment to care must be assured.

  “We had a patient recently who we really didn’t want ambulating, but he told us he had to work or he would lose his job, his insurance, and his house,” Palaisa related. “So, we got him back to work, but we made it clear to him that he had to monitor his care and communicate with us regarding any changes. We have to trust that our patients are going to keep in communication with us — and we achieve that by educating them and their caregivers.”

A Sound System

  Also central to the clinic’s protocol and structure is the support of the ancillary hospital departments.

  “Prior to us, we had a lot of family physicians and surgeons in the region who were performing wound care without the benefit of being coordinated within one health system,” said Palaisa, a former home health nurse who earned her certification in 2001 and was hired by Washington Health System specifically to help launch the clinic with former medical director Brent Angott, DO. Marks, a longtime area resident who, as he puts it, “planted his roots” after conducting his residency in Pittsburgh in 1978, joined the health system in 2009 when outpatient podiatry services were expanded. (The wound center shares a facility with the podiatric practice as an extension of hospital services.)

  “We have a great relationship with the hospital staff,” Marks said. “They do an excellent job of triaging patients and identifying those who have chronic wounds and referring them to the wound center. And that’s important, because unfortunately, in healthcare there can be a ‘gap’ between providers, which can be detrimental to the patient.”

  Still, Marks, Palaisa, and their staff embrace the center’s independence.

  “There’s a huge advantage to that because it gives us an availability to move in a particular direction faster,” Marks said. “The hospital administration continues to understand that this is a community service and they’ve continued to support us. Because of their leadership, they understand the ‘halo effect’ to wound care for ancillary services that can be provided and the success you can have.”

  The facility also boasts a patient-friendly atmosphere that can accommodate many. With today’s healthcare climate, Marks is especially proud of the clinic being adequately equipped to care for those patients “with size.” When the facility was scouted, specific attention was made to the capacity of patient rooms, hallways, and even waiting rooms and restrooms so that necessary equipment, chairs, chambers, and beds could be housed.

  “Our patients don’t have to feel ‘embarrassed’ when they come in here,” Marks said. “We’re accessible to them. You need to dedicate the space that a wound clinic needs.”

“First” In The Region

  At Washington’s wound clinic, which became one of the first in the tri-county region to offer hyperbaric therapy in 2009, the dedication may be most evident among the depth of its staff, which consists of more than 20 members, including physicians, respiratory therapists, medical assistants, and wound care-credentialed nurses who represent a philosophy shift that has also proven beneficial.

  “We take more of a ‘primary nursing’ focus to our care now, where each patient is assigned one nurse who guides him or her through their care,” Palaisa said. “Patients develop different relationships with nurses than with other providers. The development of trust really comes into play.”

  That trust is also reflected in the relationships nurses have with physicians, said Marks, adding the exposure patients have with doctors is also substantial. “Our nurses are our ‘worker bees,’ and there’s that earned respect between physician and nurses, but my partners and I are also aware that you need to have that eyeball-to-eyeball contact with our patients,” he said. “You can’t build relationships by standing at the door, talking down to everyone.”

  Palaisa and Marks say the impact the staff has on patients is documented in patient satisfaction surveys that have been tracked since the facility opened.   “The amputation rate for our hospital has decreased since we’ve opened our wound center, and the positive responses we’ve gotten from our patients have improved as well,” Palaisa said. “Everyone on this team, from the front office staff to those who discharge, we’re all operating with the same goal — establishing the relationship with that patient.”

  They both stand by the center’s impact on its patients even when the most optimal of outcomes do not occur.

  “You don’t ‘win’ with every patient,” Marks said. “But, when you build up that trust and confidence in patients by holding their hand and telling them you haven’t forgotten about them as they transition to, say, hospice care, they know that you’re trying to do everything you can to make them comfortable. And when you have those patients who were given no hope before they came to see you from their providers, and I’m talking about real hope — that’s a very powerful pill. And when we’re successful, there’s a lot of hugs and a lot of tears.”

Meet The Team at Washington Health System’s Wound & Skin Healing Center

  The Washington Health System Skin & Wound Healing Center has more than 20 healthcare staff members, each of whom plays an individualized collaborative role within the clinic. Below is a full list of all healthcare staff, titles, and credentials. Physicians: James A. Marks, DPM, medical director; Brent E. Angott, DO; Dennis P. Brown, MD; Brandon E. Crim, DPM; Gerald E. Kaufer, MD; Nicholas J. Lowery, DPM; Amelia Arianne Paré, MD; James A. Pareso, MD; Carlos Valladares, DO. Wound Care: Rita L. Palaisa, BSN, RN, CWOCN, manager; Tammy Bandini, RN, WCC; Colleen Killen, BSN, RN, CWOCN; Shelley Loughman, BSN, RN, CWOCN; Carla Miller, RN, WCC; Brenda Snyder, RN; Jennifer Anderson, MA; Jodi Astorina, MA; Stormie Price, MA. Hyperbarics: Lance Cook, BS, RRT; Judy Fenton, RRT; Kathy Higgins, RRT.

 Joe Darrah is managing editor of Today’s Wound Clinic.

Wound Care Patient Profile

A traumatic wound teaches one patient the value of his health.
By Joe Darrah

  Washington, PA — Growing up on a farm in Waynesburg, PA, Jerry Gooden, 69, was born into an environment predicated on manual labor and “pushing through” its associated aches and pains. He’s broken bones, sprained joints, and, in the not too distant future, will undergo his second hip replacement due to arthritis.

  “Pain is a part of life where I come from,” said Gooden, who now resides in Washington, PA. “It’s just in my nature to keep going.” But life for Gooden and his wife Kathy came to a screeching halt this past Thanksgiving, when he woke up to a massive hematoma the day after dropping a piece of heavy work equipment on his right leg. A bone-deep flesh wound near his shin eventually developed and required surgery and negative pressure wound therapy (NPWT) to initiate closure.

  “I knew that there was no ‘walking this off,’” Gooden told Today’s Wound Clinic during a recent visit to the Wound & Skin Healing Center at Washington Health System. Having just undergone a dressing change, cleansing, assessment, and reapplication of his NPWT dressing, Gooden reflected on his condition and experience — which included multiple trips to a hospital outside Washington’s system — and came closer to resulting in an amputation than he’d care to remember. (For an online photo slideshow of Gooden’s visit, click here: https://www.todayswoundclinic.com/slideshow/facility-focus-photo-slideshow-skin-wound-healing-center-washington-pa-health-system)

Not Your Average Bruise

  It was near noon on a cold, late-November day in West Virginia, where Gooden, the owner of a warehousing/trucking company, had driven five hours to unload more than 1,000 pounds of bulk rubber that his company had purchased overseas. Needing to remove 10 pieces (roughly 125 pounds each) of freight from a delivery truck and stack them in order to be brought back to Pennsylvania, Gooden and a partner were two pieces shy of finishing when a unit slipped from Gooden’s hands and slid down his leg with all its weight before he was able to secure his grip.

  “It didn’t hurt much at all,” he said, “so we finished the job and we left.” Too busy and not concerned enough to fully investigate the injury, Gooden said he noticed some minor scratching on his lower leg and that his leg was “weeping,” likely a sign that a break in the skin had occurred and that serous fluid began to drain, according to Rita Palaisa, BSN, RN, CWOCN, manager of the clinic where Gooden would eventually be referred nearly a week later.

  “But during the drive home I could feel my leg swelling to the point that my pants became too tight,” he said. “So, I pulled over to call my wife and let her know ‘I think I’m in trouble.” Still, what would happen over the course of the next 12-14 hours was unimaginable to both Gooden and his wife, even though Kathy pleaded with him to go to the hospital because he had developed a large, dark bruise spanning most of his leg by the time he returned home. “It was enormous,” said Kathy, who has accompanied her husband during the duration of his care, which has required three weekly wound clinic visits post-surgery and is expected to continue through February. “It was like a brush burn that overreacted.”

  After a sleepless night, Gooden decided to go to an emergency room when the pain, the bruising, and the swelling had intensified.

Hopeless Feeling

  X-rays taken revealed no breaks, so Gooden was given an antibiotic ointment, was discharged, and was told to return if the condition, diagnosed as a hematoma, continued to decline. Relieved to have no broken bones, he couldn’t help but wonder why more hadn’t been done for him given that just about every nurse and physician on staff was brought in to “get a look” at his injury.

  Two days later, they were back in the hospital because “a black hole” had begun to form on his lower leg and the overall appearance had continued to look yet worse. IV antibiotics were administered and an ultrasound was ordered, and again Gooden was discharged, this time with oral antibiotics and directions to schedule a follow-up with his primary physician. By now, real fear had set in.

  “I was legitimately scared when they told me at the hospital they were checking me for blood clots, because that could mean, stroke, death, whatever — especially at my age,” Gooden said.

  When he couldn’t get a same-day appointment with his doctor, the couple drove to the office and was immediately referred to the wound clinic for a consult the next morning. A partial debridement was performed by Brandon E. Crim, DPM, and Gooden was placed in light compression for an anticipated one-week return. But when Gooden said the pain had become unbearable after two days, Crim performed surgery, which included debridement and full evacuation of the hematoma.

Recovery Road

  Due to his daily prescription of the blood-thinning Coumadin, it’s been determined the hematoma coupled with extensive pooling of blood beneath the skin caused significant swelling and skin breakdown. Originally measured at 148.5 sq cm, after six weeks of NPWT therapy the wound had reduced to 13.1 sq cm.

  “Now we’re getting to the point where we will use an advanced biological tissue substitute to get full closure,” said James Marks, DPM, FACFAS, FAPWCA, clinic medical director. “His wound, had it continued to progress and gotten an aggressive infection in the soft tissue or possibly the bone ... he could have been looking at an amputation.”

  A self-proclaimed procrastinator who doesn’t see the doctor until it’s “past time,” Gooden admits he probably endangered his health by not going to a hospital sooner. However, he insists that had his course not led him to Washington, he might have had a worse outcome altogether.

  “The way they care about you here is just amazing,” he said. “I know it sounds cliché, but it’s hard to describe what something is like when it’s better than you could have ever imagined. I haven’t even missed a day’s work, though I’m only on desk duty now. It’s been remarkable.”