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Facility in Focus

Achieving Limb Preservation Through Education & Multidisciplinary Care at Swedish Wound Center

As a lawyer, Jerome Crawford has always possessed an innate ability to be exhaustingly analytical and to question anything that seems suspicious or shortsighted. So when he was recently told by surgeons at a local hospital that there was “nothing that could be done” to treat a diabetic foot ulcer (DFU) on his left heel other than to perform a below-the-knee amputation, Crawford, as he would so often be inclined to do within a court of law, objected to the prognosis.

“They told me they wanted to amputate, and I told them ‘no,’” said the 67-year-old Kent, WA, resident, who, following a transient ischemic attack he experienced this time last year, required a short-term rehabilitation stay at a skilled nursing facility that led to the development of the ulcer. Within a week of being discharged home he was back in the hospital due to the foot infection, where he said a perceived lack of initiative made him anxious. 

“It seemed like nobody wanted to try to fix this — that there was no hope for me and that they all saw it as a waste of their time,” he said. “From a personal standpoint, I don’t think like that. I wanted a second opinion.”
That desire to seek out more answers led Crawford to the Wound Healing Center at Swedish Medical Center in Seattle, where today he’s expected to fully heal after what has been about eight months of comprehensive wound care treatment for a gangrenous, infected wound. The wound measured 7 cm x 4 cm when he was admitted to the hospital’s Cherry Hill campus in the city’s downtown district for an inpatient stay to debride and treat the infection. As of press time for Today’s Wound Clinic, the most recent measurement came in at 1.8 cm x 1 cm with granulation. 

As it turned out, the staff at the outpatient clinic agreed with Crawford’s assertion that more could be done to save his foot. 

“He had been told, based on a combination of poor circulation and advanced nature of the ulcer, that he needed an amputation of his foot; but Jerome is very well educated and wasn’t willing to accept that recommendation,” said Rocco Ciocca, MD, FACS, chief of vascular surgery at Swedish and medical director of the Wound Healing Center at Cherry Hill. “Mr. Crawford is now pain-free, infection-free, has his foot, and his overall prognosis of keeping the foot and maintaining his independence is excellent.”
While it would take several weeks of comprehensive wound care before he received a favorable and encouraging prognosis, Crawford said the good news was something he was comfortable waiting for if it meant the assessment and information he’d be given from his clinicians was supported by comprehensive analysis as opposed to conjecture. 

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“They made no promises here, but they told me ‘we’ll try to heal you,’ and that’s all I was asking for — for someone to try,” he said. “They told me the care plan they wanted to go with and they’ve been very meticulous, very cautions, and very caring. I feel so fortunate that I ended up here.”
Ciocca attributes the success seen thus far not just to Crawford’s ambitious attempt to achieve the correct diagnosis and treatment, but to his clinic and its staff’s multidisciplinary approach to care and education. That approach, Ciocca said, operates in such a fashion that each patient’s circumstances and care plan are objectively evaluated among each discipline throughout a wound care team that fosters collaboration along the spectrum of care. 
“The work that we do in this clinic is not about the physicians telling the nurses and therapists what to do — it’s about all of us seeing the patients together and coming to a consensus — including as to what the approach should be with each of our patients,” Ciocca said.

Assurance of Appropriate Wound Care Protocol
Referred to Ciocca and the outpatient clinic through his primary physician, Crawford was at the very least in a precarious state when he arrived to the clinic wound center about eight months ago. That can be said without refute, Ciocca insisted. 

“This was a horribly infected, foul-smelling, gangrenous calcaneus ulcer,” Ciocca said. “By the time he was referred to me in my vascular office, this was a very severe and advanced diabetic ulcer and this is a gentlemen who by all accounts ‘needed’ his foot to be amputated. But with his hospitalization and then through a combination of outpatient therapies including serial debridements, we’ve gotten what was once a completely exposed ulcer to a size and granulation that we hope will be completely healed soon.”
His inpatient stay at Swedish lasted about one week, during which time Crawford also underwent an angiogram and an angioplasty of his tibial vessels to improve circulation to the foot, which was operatively debrided while he remained in acute care as the infection cleared. This treatment followed a week’s stay in the hospital he had visited after his rehab stint. 

“I needed to go in after returning home from rehab to receive antibiotics and had an angioplasty, but then they told me they wanted to schedule me for a below-the-knee amputation to take place the following week because ‘there would be no way to get blood to the wound to help it heal,’” Crawford explained.

Diagnosed with type 2 diabetes in his late 40s, Crawford said to date he’s only incurred one other DFU. This resulted in the amputation of his right big toe five years ago, but has not significantly affected his gait. The development of the recent ulcer and the subsequent treatment and education he’s received at the clinic has actually led him to no longer be insulin-dependent, a status he’s been able to claim for about two months, he said. He’s soon expected to be discharged and be given clearance to return to his post-retirement career as a teacher. 
The alternative for him was rather dire with the direction the ulcer was previously headed, according to Ciocca, who emphasized that appropriate patient education in this situation has gone a long way to producing the favorable outcomes now being seen.

“Particularly for diabetic foot wounds, things like making sure people have proper footwear and making sure patients are changing their socks and washing their feet is really important,” he said. “It’s not always self-evident. Proper skin care and offloading are also taught on a daily basis. Supporting patients by helping them avoid risk factors, such as smoking, and educating them on the negative impacts, such as heart disease, coronary disease, peripheral arterial disease, vasoconstriction, and hypoxia. Through a lot of hard work and the patient’s commitment to buying into the care plan and working with us through some difficult procedures, we have been able to get him on a path toward healing. It’s been a very fulfilling case, and I’m proud to say that we’re able to provide that sort of service on a frequent basis.”

Fostering Encouragement Through Education
Betty Halfon, a 62-year-old patient recently discharged from Swedish’s wound clinic, represents a similar story of insistence to seeking appropriate care that has led to limb preservation, even if her clinical circumstances vary from Crawford’s. A cancer survivor who was diagnosed with non-Hodgkin lymphoma at age 27 and breast cancer two years ago, Halfon has long been accustomed to the demands of medical care plans and has over the years developed a mentality in which she strives to learn the clinical “whys and hows” of her health to better understand her particular diagnoses and the science behind healing. 

“I am not afraid of going to the doctor or the hospital; I want to know what’s going on,” said Halfon, a Seattle resident who was recently discharged from the Swedish clinic after undergoing treatment for Charcot foot, the second time she’s developed the condition since her type 2 diabetes diagnosis 20 years — a result of her cancer meds and her self-described lifetime struggle with weight issues. “I’m not naïve to what has happened to my body over the years. I tell people that I should be a study in medical history because I’ve taken so many chemo drugs in my life.”
One who’s endured five separate occurrences of lymphoma as well as seven miscarriages and a tubal pregnancy, Halfon initially didn’t panic when her podiatrist confirmed a second stint of Charcot had set in about one year ago. 

But after about seven months of outpatient wound care that produced no progress, a lot of pain, multiple infections, and increasingly limited ability to walk, Halfon said she seriously began to question the effectiveness of the treatment she was getting and, even more, the willingness of her providers to honestly and effectively communicate what was actually occurring with her wound and overall health. She said she was especially concerned with the amount of time she needed to be on her feet to attend the wound clinic there times per week on top of twice-daily visits to the hospital to receive IV treatments for an infection that didn’t subside. Prescribed to wear a CROW walker, Halfon said she’d often be forced to take it off to enable driving to her appointments, which she said were too numerous to rely on friends and family to transport her each time. When hyperbaric treatments were introduced at a rate of five per week for three months and a wound vac was applied but quickly discontinued because it wouldn’t remain of place, Halfon said she desired a change in scenery, which she assumed would bring with it a change of care plans. 
“The whole time I was feeling like nobody ever told me what was really going on or how my wound was looking,” she explained. “I knew something wasn’t going right because things weren’t getting better for quite some time. So, at one point I told them ‘I don’t want to be here.’”

Insistent to complete the hyperbaric sessions before seeking another facility, Halfon would often become ill with fevers, topping at 1030 over the Thanksgiving holiday, and eventually visited the emergency department at Swedish, where she was diagnosed with sepsis and underwent emergency surgery to remove infected bone from her mid-foot. She remained in the hospital 10 days before being seen in the outpatient clinic.

Though the wound had been open for several months before Halfon presented at Swedish, clinical supervisor Sally Munn, DPT, CWS, said the protocol for Halfon did not stray from what is considered to be the standard approach to care at the clinic. It was determined, however, that she would not be using the walker in lieu of an insole and custom shoe. Halfon was also advised to no longer take showers while the wound persisted and to self-offload with the use of a wheelchair, and would require only weekly clinic visits with the infection gone.  
“Betty received the care we’d give to anyone who’d have her problem,” said Munn. “She lives with neuropathy due to her diabetes, so we also needed to take the pressure of the bottom of her foot. We used felt offloading and local wound care to manage the wound. Certainly the protocol for her was to offload, and once her foot was healed we brought in an orthotist and will continue to work with her after discharge.”

Fully healed in under eight weeks, Halfon was transitioned home in early February and has continued to see a physical therapist in the hopes that she can one day resume her once-typical 5-mile walks she’d schedule multiple times per week around the neighborhood with her pet dog Schroder, an 11-year-old, mixed-bred Labrador/Newfoundland. Committed to keeping her pooch and herself healthy since undergoing bariatric surgery three years ago, Halfon has slowly but progressively amped up her walking as deemed safe by her network of providers. At Swedish, the level of communication and patient involvement in the healing process was commensurate with her expectations.

“They would take pictures and show me how things were progressing,” she said. “And I was beginning to see results. They treat patients like you’re a human being who can talk with you and learn about healthcare. I have to be careful with how much I walk, but I’m walking again. And I have my foot. It’s amazing.”

A store owner in Pike Place Market, a public shopping district overlooking the Elliott Bay waterfront in Seattle and considered one of the oldest continuously operated public farmers’ markets in the US, Halfon has also gradually been afforded the opportunity to spend more time at her shop as well as with colleagues on the council that governs the market itself.

“She’s an active member of her community and wants to be able to walk, so we’ve helped her understand how far she can walk and to use her energy and walking time for what it’s best suited for,” said Munn, who credits the patients themselves with serving as an extension of the provider through in-clinic education and encouragement that’s meant to help them remain informed of their health prognosis throughout their length of stay as well as aware of wound progression. Despite being discharged, Halfon received post-wound care instruction aimed to prevent further ulcers. 
“Her responsibilities are to inspect her feet twice daily, monitor her blood sugar, to always have shoes on her feet whenever they hit the ground, and we had a long discussion about distances she should walk and distances she shouldn’t,” Munn continued. “When assessing her feet, she needs to look for any redness or swelling, areas of pressure, blood or drainage on her sock, or any changes in the structure of her foot. A lot of education needs to be part of the treatment, especially for those with neuropathy and foot deformities, because even though the wound has healed and she’s in an adaptive shoe, she could still be at risk for breaking down. But Betty was a model patient when she came here with doing what we asked of her to help in the healing process. If she had questions, she asked them. And she walked out of here on her last day. That was very rewarding to see.” 

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

Wound Clinics: The ‘Ideal’ Quality-Care Environment 
As the US healthcare system transitions to value-based care, no patient population may play as integral an involvement than the 5.7 million Americans who live with a chronic wound.1 Consequently, clinicians involved in the treatment of these patients will likewise contribute significantly to the inherent success this change in scope will demand. And within that cohort it may very well be the outpatient setting in particular that provides the optimum opportunity for the idea of quality care to be realized, according to Rocco Ciocca, MD, FACS, chief of vascular surgery and medical director of the Wound Healing Center on the Cherry Hill campus of Swedish Medical Center in Seattle.
“The wound center as we know it is almost ideal for the changing healthcare environment because we keep people out of the hospital for the vast majority of their care, we keep them living at home, we keep them pain-free and infection-free, and we do so at very modest costs in comparison to inpatient therapy or, unfortunately, if they require a major amputation — which could be the difference between an elderly patient’s ability to live independently or succumb to living in either assisted living or skilled nursing,” explained Ciocca. “And certainly it has been shown that once patients lose their independence, their quality of life is diminished and their length of life goes down. In that sense, we in the outpatient wound clinic are at the forefront of modern healthcare in that we’re keeping complex patients whole, literally, away from the use of narcotic prescriptions, and vastly enhancing their quality of life. ”

At Swedish Hospital, Ciocca and his fellow wound care providers say they are taking the opportunity they have given the present flux of this country’s healthcare delivery to make a significant impact on patients and the system as they can.

At Swedish, that means maximizing one-on-one time to educate as well as to assess the level of how well education has been received, Ciocca said. “Our patients spend a lot of time with us, so there’s a lot of opportunity for us to look for signs that they’ve absorbed what we teach them,” he continued. “When you have the good fortune to be able to see people over a long period of time, you can touch on those topics repeatedly and determine if they’re understanding you or if you need to approach things from a different direction. We develop a long-term relationship with these patients in the time we have with them, so they trust us and will ask us questions when they’re here. It’s standard to what we do here.”

Also standard is the repetition of education and assessment from the staff in a clinic that includes a physician panel, registered nurses, and therapists. 

“All of our care is collaborative, and so our patients hear the same message from everyone who cares for them,” said Sally Munn, DPT, CWS, clinical supervisor at the wound clinic. “And the staff here makes it clear to patients that they should ask any questions they might have, and we’ll look for any feedback we can get, because part of educating is making sure the patient understands what you expect of them.”

That said, there’s always some trust that clinicians must commit to their patients when it comes to how they actually implement what they’ve learned into their daily lives, especially after they’re discharged. 
“It can be a difficult adjustment at that point as a provider, that’s why we try to provide education along the way as opposed to the last day — so that there’s a real understanding,” Munn said. “For those living with diabetes, we insist they follow up with their primary care doctors if their blood sugars aren’t in line and discuss how important it is to monitor activity and wear the appropriate footwear. So, hopefully by the time they’re discharged, it really is OK to let them go. But our patients also know that they can call us or come in for checkups if they have any problems with their healthcare or complications with their footwear or equipment.”

The establishment of the Providence-Swedish ACO of Washington, which hospital administration announced in December, has been selected as one of 123 new accountable care organizations in Medicare, providing approximately 1.5 million more Medicare beneficiaries with access to high-quality healthcare, has strengthened the facility’s commitment to quality. 

“We live in a world where everybody wants everything done ‘right away,’ but outpatient wound care allows us to take a breath, to be patient, to work collaboratively amongst various disciplines, to see patients repeatedly, to get to know them as people and individuals, and to make adjustments — if something’s not working to shift gears and try different things,” Ciocca said. “[The opportunity] to investigate issues including infection, blood supply, nutrition — to alter and tinker with those various variables to optimize the patient’s ability to heal — that’s a significant benefit to working with us in the wound center.” 

Reference
1. Branski LK, Gauglitz GG, Herndon DN, et al. A review of gene and stem cell therapy in cutaneous wound healing. Burns. 2009;35(2):171-80. doi: 10.1016

Facility in Focus
Joe Darrah
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