Cath Lab Digest

The beginning is the most important part of the work. — Plato

Since the ancient Greeks first put honey in wounds, our comprehension of wound management has been a slow but steady journey. An understanding of the germ theory led to sterile, dry dressings and frequent antibiotic scrubs. The original work by Dr. George Winter, published in 1962, demonstrated the value of a moist wound environment. Now, recombinant DNA technology and genetic engineering hold out the possibility for growing replacement tissue s and blood vessels. Between these extremes lie semi-synthetic human skin, dermal scaffolds, hyperbaric oxygen therapy, negative pressure therapy, topical growth factors, and a billion dollar dressing industry.

Wound management crosses all disciplines from physical therapy to plastic surgery and includes podiatry and dermatology. Within a single hospital, clinicians manage postoperative wounds from pediatrics to geriatrics, acute wounds from the emergency department to the burn unit, and chronic wounds from the intensive care unit to the long-term care unit. Some wounds improve and some deteriorate. The reality that patients with multi-organ system failure can “outlive their skin” is ignored by public policy that assesses monetary penalties for pressure ulcer formation regardless of comorbid factors. The disconnect between patient or family expectations and physiological reality can create a medicolegal quagmire for a hospital unprepared to handle the collateral damage of patients who are being admitted older and surviving longer, but sicker. Although these insidious problems are pervasive, in a large organization such as a hospital it is easy to understand why administration may not comprehend the full impact of skin and wound care issues on the institution.

An estimated 800+ outpatient wound centers are in operation in the US, not including all the wound care rendered by clinicians in their offices. Studies suggest that patient outcomes are better when care is provided in an environment of focused expertise. To quote Dr. Allan Freedline, “… a systematic approach to wound care … leads to superior clinical outcomes, positive revenue streams, and well deserved community accolades.” These centers generate income for the hospital via tests and procedures; additionally, the wound center addresses inpatient wound care challenges, helping decrease runaway wound-related expenditures.

A hospital has the potential to reduce inpatient length of stay and address a significant unmet need in the community when a wound center is established. To do so without exquisite preparation and planning can lead to frustration and failure. However, careful planning and early investment in resources can lead to success.

General Planning
Key players. From the beginning, there must be buy-in both from the folks who approve plans and budgets and those who take the plan to the hospital’s Board of Directors, many of whom are leaders from the community that you will serve. The hospital’s CEO and CFO should be well informed of the options for program development and become champions of the cause. Include your medical staff office, as well as the marketing team, for ideas about future internal and external marketing needs; they are the resources who will plant informational seeds in the community, identify potential referral sources, and ascertain the perception of need in the medical community.
Research your service area. Knowledge of the demographics of the community based on known epidemiological data can assist in projecting the potential needs. Additionally, knowing the current diagnostic trends in the inpatient population (ie, diabetes, cardiovascular disease, patients admitted with wounds) can help predict potential wound care needs.
Location, location, location. Determine your proximity to other medical services, patient access, visibility, options for expansion, cost per square foot, and the challenges for equipment installation (eg, hyperbaric chambers). Will you be on- or off-campus? A brief consultation with your hospital legal team will help you understand the potential ramifications to your hospital’s global provider status if you elect to utilize a management company in an off-campus situation.
Know your competition. Find out if there are other similar outpatient programs in the community. What are their strengths and weaknesses? Will you compete for the same patients or the same physicians?

Perform a market analysis. Evaluate your service area mix, starting with the postal codes for your patients. Hospital marketing can help you assess primary and secondary service area populations to allow you to estimate payor mix.

Space Planning
Physical plant. The clinic space must include individual treatment rooms with sinks, adequate front office space, offices, waiting area, clinical workspace, a dictation area, storage areas, and clean and dirty utility rooms. If your plans include a hyperbaric program, you also will need patient changing rooms in addition to oxygen supply, fire safety, and floor weight loading, with consideration to the wax on the floor and the types of lights in the ceiling. It is imperative to consult with individuals qualified to assist you with these unique requirements early in the planning.
Treatment room equipment. Podiatry chairs or stretchers, Mayo stands, visitor chairs, and either installed or mobile lighting are the minimum for a properly equipped treatment room. Consider whether counter space in the treatment rooms, as well as space for documentation (electronic or otherwise), is adequate. Don’t forget the basics — thermometers, sphygmomanometers, needle boxes, glove boxes, dirty linen containers, trash cans, and hazardous waste receptacles.