It wasn’t that Gregory G. Mukalian, DO, FACOS, didn’t believe what he was told. He just didn’t want to think it could actually be true — that his new patient, 31-year-old Shannon Gettis, could have been previously brought into an operating room and opened up six times due to a staph infection she had developed postsurgically after the repair of an umbilical hernia.
But here he was, with the patient again open and on the OR table, exploring her abdomen during what would be her seventh — the first under his knife — and ultimately final procedure. Sure enough, the clinical and physical evidence that he found that day, some four months removed from her initial surgery, convinced him that she had not exaggerated the details of her prior care. Care that began with an elective surgery to repair the hernia this past March.
Today, just three weeks into an inpatient stay at Lourdes Specialty Hospital of Southern New Jersey, Willingboro, Gettis is ready to be discharged and transferred home as well as into the care of Lourdes’ outpatient wound center, where Mukalian serves as co-director.
A mother of three from Burlington County, NJ, Gettis was referred to Mukalian by a family friend on staff at Lourdes when she sought a second opinion following months of physical pain, emotional distress, anxiety, and a hopeless feeling that the multiple procedures she had been through were actually making her more sick.
“It was just constant pain, nausea, and fever,” Gettis said during a recent visit by Today’s Wound Clinic to Lourdes Specialty. “I knew something was wrong, and sometimes I wonder what would have happened to me if I didn’t come here for that second opinion. And that’s a scary thought.”
For Mukalian, the patient’s condition was rather frightening as well, even for the standards of a well-seasoned surgical specialist.
“When we took her into the OR here, we suspected and eventually learned that what she had been dealing with was a retained infection from the old mesh that was used to repair the hernia,” said Mukalian, who also serves as chair of the wound care program at Lourdes Specialty. “The incision had closed over, but there was a lot of thickening and scaring to the skin at the incision site, proof that she was not embellishing her story. She had a legitimate problem.”
The infection had not only compromised the hernial incision, it had also spread throughout her stomach, into another previously closed surgical wound from a C-section she required last year for the birth of her third child, and even to the bone of her right hip (although luckily for her not into the bone).
“Hopefully, this is the end of what’s been a long road for her,” said Mukalian, who anticipates Gettis will need two more weeks of wound vac treatment and postoperative antibiotics (she’s currently on Zosyn) as well as weekly visits to the wound clinic for up to a month’s time or complete wound closure, should that occur sooner.
The odds of a quicker healing rate within the outpatient setting are expected to be good considering the optimal condition Gettis has reached at Lourdes Specialty, a long-term acute care (LTAC) hospital, which has included the oversight of infectious disease specialist and infection control program director John Peterson, MD, as well as a systematic multidisciplinary approach to wound care by the hospital’s staff of specialty trained nurses and therapists. As a collaborative venture, the inpatient LTAC and outpatient wound clinic, both of which are located on the same campus, have strategically developed a protocol that administrative and clinical staff have credited with greatly reducing the number of short-term acute care hospital readmissions needed among patients throughout the service region (including parts of Pennsylvania, New Jersey, and Delaware) thanks to a level of care that they believe to be unrivaled in the Delaware Valley.
“This hospital’s reputation has grown exponentially over the last 18 months, really one patient at a time,” said Cheri Cowperthwait, RN, chief executive officer. “And we’ve distinguished ourselves through the care that we provide here. I think the physicians whose patients we care for from both within and outside this community are happy that their patients have the opportunity to receive care here.”
There’s evidence to back up these assertions. In June, Lourdes Specialty earned an award for excellence in skin safety from the Wound Ostomy and Continence Nurses (WOCN) Society and 3M Critical & Chronic Care Solutions (See sidebar).
Lourdes Specialty Hospital Earns 3M Award for Skin Safety Excellence
3M Critical & Chronic Care Solutions Division and the Wound Ostomy Continence Nurses (WOCN) Society recently awarded Lourdes Specialty Hospital of Southern New Jersey, Willingboro, with an award for excellence in skin safety.
The facility’s wound care program was selected for its mission to ensure prevention of new wounds through a program that’s provided outstanding wound monitoring, tracking and reporting methods, comprehensive staff training, and extensive patient education, according to 3M and WOCN officials. As part of the honor, the facility received financial support through an unrestricted educational grant to attend the annual WOCN conference in Nashville, TN. To compete for the award, facilities were invited to submit summaries of skin care programs that have achieved measurable and sustained results in the area of skin integrity. The programs also had to demonstrate prevention protocols; comprehension, accessibility, and user-friendliness of product formulary; interdisciplinary participation; senior leadership engagement and frontline autonomy; and creative and effective staff and patient education. A panel of WOCN members selected by the WOCN society judged entries.
“It’s not just about a piece of equipment, or a dressing, or a particular product – it’s the overall collaboration and team approach to what we do here,” said Kimberly Fetterolf, RN, chief clinical officer, at Lourdes Specialty Hospital. “This award shows that all the training, education, and protocols that we have committed to has produced positive outcomes. It’s about everyone working together towards the same goal.”
— Joe Darrah
Such accolades have brought with them more notoriety as well as additional patients and referrals.
“Up until recently, we were what I considered to be the best-kept secret in the Delaware Valley,” Cowperthwait said. “And it wasn’t that long ago that we didn’t have enough beds to even consider marketing ourselves throughout our surrounding communities. Today, people come to us for our opinions.”
Literally, the reputation and collaboration have grown with the facility itself.
Comprehensive & Expansive Efforts
The first facility of its kind in southern New Jersey when it was built nearly nine years ago as an 18-room floor licensed to care for as many as 30 patients, the LTAC at Lourdes Specialty has since grown to a 54-room, 69-bed hospital that encompasses two floors and 40,000 square feet thanks to a $9 million hospital expansion in March 2013 that not only resulted in more than tripling the LTAC’s size and capacity but included the hiring of nearly 150 new staff members and brought the total number of physicians to just more than 200 at the facility.
“We’re a ‘hospital within a hospital,’ a federal determination that has to do with how far you are located from the main facility, which is the short-term acute care hospital,” Cowperthwait said.
The expansion also brought with it more safety equipment, including an integrated lift system that has become necessary as obesity rates climb in the US.
“There’s a lot of focus on safety here,” Cowperthwait said. “We have ceiling- or wall-mounted lifts in about 65 percent of our rooms, and over the next couple of years we expect to be at 100 percent. They’re expensive, but they’re well worth it and have been a great help to the turning protocols we have in place and certainly help keep our staff safe.”
Traditionally known for predominately caring for a respiratory patient population that by and large requires ventilator weaning — about 70 percent of LTAC patients arrive on ventilators — Lourdes Specialty now typically treats an estimated 1,000 wounds during any month, according to Cowperthwait. Many of these patients are also admitted on a vent and are living with various integumentary problems as well as hospital-acquired pressure ulcers or nonhealing surgical wounds from referring hospitals, skilled-nursing facilities, outpatient clinics, etc.
“These are all very sick patients, many who have spent weeks or months in an ICU before getting here,” she continued. “So, we’re really an extension of the ICU.”
The overall dynamic of wound care at Lourdes is likewise not easily pigeonholed. As in the case with Gettis, patients are known to be transferred from the inpatient side into the outpatient center just as fluidly as they can be referred from the outpatient setting into the LTAC for more continuous care for particularly challenging wounds, infections, and comorbidities as appropriate per LTAC admissions acuity criteria.
Outpatient & Inpatient Co-Op
Initially established along with the short-term hospital, the outpatient wound clinic welcomes about 300 visits per month, with a majority of patients cared for and healed strictly on an outpatient basis. However, a small number of admitted patients are assessed to be in need of care that significantly exceeds the level of resources that clinic physicians objectively determine they’ve got to manage and heal wounds in a reasonable period of time. For these individuals, the LTAC is one phone call and only a few more paces from the center.
“Severe infections of the wound, osteomyelitis of the bone, occasionally a patient who has cancer of the skin who has been treated with radiation and needs a high level of care with hyperbarics … these are some conditions for which we’re going to consider referral to the LTAC,” said Louis S. Ruvolo, MD, FACS, FAPWCA, co-director of the outpatient center. “We have a fair number of patients here who will meet a level of care that requires hospitalization, but the acute care hospitals can’t keep them more than 2-3 days because there’s such pressure to get people out of those facilities quickly. But we have the benefit here of being able to admit them to the LTAC, where they’re going to be able to spend a longer period of time with some of the best providers I’ve ever known who can address their problems. For any wound clinic that might have a patient who could use more than a couple days in the hospital to really facilitate healing, the LTAC can be a good way to achieve that. But there aren’t that many LTAC’s around.”
One of a reported two LTACs in South Jersey, Lourdes Specialty and any other LTAC requires rather stringent criteria for admission. According to the American Hospital Association, patients must have an average length of stay of at least 25 days and meet Medicare’s conditions of participation for acute care hospitals in order to qualify for Medicare payment in an LTAC.
“Certainly, not all patients are going to qualify to come here,” Cowperthwait said. “There has to be a viable opportunity for us to improve the patient’s condition and move them along the continuum of care, and the severity of illness has to require an intensity of service that meets inpatient criteria. Even as wound care treatment has moved more toward the outpatient side, a place like Lourdes Specialty Hospital becomes more important because, as hospitals evolve into a very narrow set of product lines and services, there is still this population of patients whose needs are more intensive and can only be serviced well in an inpatient LTAC. We develop a plan where we can put them on a road toward healing and safely discharged to the outpatient wound center.”
Providing Systemic Care
As with any inpatient or outpatient healthcare facility operating today, wound care at Lourdes Specialty has become an increasing aspect of everyday patient care as more patients at all levels of acuity live longer with chronic wounds that require a team approach to care by those with a well-rounded education as to etiology, assessment, and treatment across all disciplines along the continuum. According to Cowperthwait, wound care at Lourdes is receiving the attention it demands through the utilization of a case-management approach to bedside care; an internal collaborative protocol involving physicians, nurses, and therapists; a particular emphasis on avoiding nosocomial ulcers and infection prevention (see sidebar); a newly instituted early-mobilization program that helps sedated bedbound patients, including those on ventilators, become active more quickly to facilitate quicker healing and allow for patients to be as ambulatory as possible at the time of discharge (see sidebar); and an onsite pharmacy that dispenses an average of 40,000 medication orders per month, including antibiotic-impregnated vacs for wounds, and practices a medication reconciliation program that requires staff to ensure local pharmacies and facilities receiving discharged patients are appropriately stocked with needed medications and products at the time of discharge.
Infection Control Program of Particular Importance at Lourdes Specialty LTAC
If you were to devise a map of the overall healthcare landscape pinpointing where all of the existing antibiotic-resistant organisms are located, there’d be a lot of red marks in the area designated for the long-term acute care (LTAC) hospital settings. John Peterson, MD, infectious disease specialist and infection control program director at Lourdes Specialty Hospital of Southern New Jersey, Willingboro, is well aware of this.
“The control of these bad ‘bugs’ is a serious challenge in the LTAC environment in this country,” he said. “Chronicity, including chronic, nonhealing wounds, is one of the major predictors of these organisms. It has become more challenging in all of healthcare to treat antibiotic resistance, and from the perspective of wound care, most of our patients are already coming in with an adjacent or underling chronic infection.”
As such, Peterson has led the development of what he describes as a rigorous infection control program that starts with comprehensive surveillance of all patients on admission and continues through the duration of stay.
“Most patients are already identified as having drug-resistant organisms when we receive them, so they’re on precaution [antibiotics] from Day 1,” he explained. “We scan for MRSA (Methicillin-resistant Staphylococcus aureus) and drug-resistant gram-negative organisms. Our staff also tends to isolate new admissions until they get that ‘stand down’ order. We check for the presence of bacteria for those who have foley catheters, central lines, and airways.”
A recent expansion to more space, more rooms, and more patients at Lourdes Specialty has not done anything to quell the challenges that Peterson and the staff face. However, he claims the willingness of administration and the dedication of staff have allowed for infection control measures to adapt to the growing LTAC, a benefit that Peterson is sure that not all hospitals have even though they’re likely to have the same intentions to remain as infection-free as possible.
“Most hospitals have wonderful policies that address everything necessary as far as infection control goes,” Peterson said. “Policies are rarely the problem. The question usually is, do you actually have the resources to implement those policies. If your staff-to-patient ratio is not appropriate things will not happen as they should. Here, we’re fortunate enough that our resources actually allow us to follow our policies because it is actually a time burden to practice good infection control. You need to be given the time to do that.”
For instance, Peterson said he’s able to anticipate that the wound care staff on the LTAC will turn the patients every two hours because patient-to-nurse ratios support that protocol.
A member of the Lourdes Specialty staff more than nine years, Peterson said he was initially intrigued with the challenge and opportunity to help launch the LTAC nearly 10 years ago, despite the impending difficulties he’d be inheriting, because he observed a true need among patients in the short-term acute realm.
“I was especially interested in the idea of the LTAC opening here because I had noted that patients with serious infections who needed longer courses of therapy with difficult regimens were being underserved in the rehab setting,” he said. “That’s just not an ideal clinical situation for all hospital patients. These patients needed to stay in an acute level of care for a longer period of time.”
When the question arises from the outpatient side as to whether patients could benefit from an LTAC stay from an infection perspective, Peterson meets with outpatient physicians to assess the situation and determine a course of action that results in a comprehensive method of care.
“The outpatient center may call us if a wound is failing, or if they think it’s going to fail, or if an infection that occurs to the bone is something the providers believe could warrant more aggressive therapy,” he said. “We’re fortunate here in that we can also do inpatient hyperbaric therapy — which is not usually available in a general inpatient setting — so that we can combine IV antibiotics, surgical wound care, bedside and operative debridement, nutritional support, diabetes control, offloading, and even making sure that people are wearing Bipap at night.
Of course, due to the nature of drug-resistant organisms, home transfer is also something that’s always part of the consideration.
“We’ll talk about whether or not the patient is a candidate for IV antibiotics at home, for instance someone with a chronic osteo with an organism that can be treated with a relatively safe regimen, or determine if they need inpatient multidrug therapy,” Peterson said. “In some instances it may make more sense to treat in an LTAC because, one, you may get more reliable outcomes, say, by avoiding antibiotic toxicity, and, two, you may get better efficacy by being able to push medication levels higher if patients get into trouble. That’s especially important when you’re talking about lower extremity infections and those that aren’t so easy to see on follow up, such as an infection to the spine.
Consider Kathy Geiger, 64, a postsurgical transfer patient from New York who recently underwent elective thoracic surgery at another facility due to the presence of an aneurysm on her coronary artery who experienced ischemia to the spinal cord, subsequent paralysis from the waist down as a consequence to the procedure, and developed an infection to an incisional wound of more than 30 centimeters long along her chest wall. Her ribs were actually exposed upon arrival, Peterson said. While unfortunately the paralysis will not be something reversible during her stay, she’s sure that the staff at Lourdes Specialty has given her the chance to live as healthy and fully as possible by keeping her free of infection.
“They absolutely saved my life here,” she said. “It’s such a great hospital and the staff has just been so great to me.”
— Joe Darrah
“Wound care is everybody’s business here,” Cowperthwait said. “Culturally, we base our care on a system that reflects the same general beliefs – that patients should not come into a hospital and acquire a pressure ulcer or an infection and that everyone has the tools they need to take care of our patients. And I admire all our staff for the care that they provide here.”
A former bedside nurse, Cowperthwait believes the insight that she has as a nurse has lent itself to not only being able to step in and provide clinical guidance as needed on occasion but to be able to predict the challenges that nursing staff may face in living up to such demanding protocols and standards, which have resulted in the LTAC not experiencing any stage III or IV nosocomial ulcers over the last three years.
Mobilization Program Gets Sickest of Patients Functioning at Lourdes Specialty
If they really wanted one, the nursing and therapy staff at Lourdes Specialty Hospital of Southern New jersey, Willingboro, could use a reasonable excuse to keep their sickest, most immobile of patients bedbound. But even though an estimated 70 percent of their patients are admitted on a ventilator, with the vast majority living with multiple chronic, nonhealing wounds, particular attention is being focused on making sure they gain and resume functionality almost as soon as they’re brought through the doors.
“It’s become a popular question among this patient population – how do we keep people who are on a ventilator up and moving?” said Beth Reeves, OT. “One of the things we’re doing as a part of complete interdisciplinary care and to improve outcomes here is following protocols that requires us to start moving patients — from range-of-motion exercises to sitting up in bed to getting out of bed — as soon as possible. We don’t just want people laying in bed. That only makes you weaker, so we want to step things up for them.”
Designed as a collaborative effort among physician, rehab, nursing, respiratory, and wound care staff in the long-term acute care (LTAC) hospital at Lourdes, a newly implemented early-mobilization program has staff buzzing about its progress in helping people become more active. Activity can be as simple as movement of limbs to sitting up or walking with the assistance of staff members.
“In our research we’ve found that it is safe to move people even if they’re on a ventilator,” Reeves said. “Everyone gets a daily assessment, and if they’re hemodynamically stable — they’re not having a heart attack, they’re not actively bleeding — they will start range of motion. If they can tolerate that we’ll continue to sitting up to standing up. It’s all about what we refer to as the PATH — patient advancement through healing. We’ve found that if we start moving patients, many who’ve been in a hospital setting before coming here, it can be a great way to promote healing and reduce infection.”
The program also stresses compromise among all clinic staff during patient rounds as a means to temper expectations related to helping patients be active — a checks-and-balances system of sorts.
“As therapists, we always want to get patients out of bed,” Reeves said. “But we have set guidelines and talk with the physicians and nurses about those with lower extremity issues to ensure they can be weight-bearing. Our goal is to get them moving without injuring their skin or risking a fall, and that’s what we’ve been able to do.”
Patti Bozzi, RN, said the nurses also rely on the therapists to provide guidance on turning protocols and posture to help those patients who are healthy enough to ambulate do so safely.
“The therapists will be there to make sure we’re using the appropriate equipment to have a patient sit in a chair or be turned while in bed,” she said.
— Joe Darrah
“A stage III or IV wound that is not healing or getting worse in another setting is a potential reason for admission,” Cowperthwait said. “We find that these patients in particular have a number of comorbidities and severity of illnesses that require many services that we can provide here.”
Lourdes also has educational protocol in place that requires new nurses to conduct their own assessments on admission and throughout patient stays that are compared with the assessments of the WOCN in an effort to ensure that comprehensive wound assessment skills are maintained among all staff regardless of tenure.
“They’re taught how we’re doing assessments as experienced nurses so they know what we’re looking at and so that those expectations are there for them as new nurses as soon as they join the staff here,” said Susan Lendacky, RN, WOCN.
Upon referral, wound patients are administered head-to-toe assessments on Day 1 by a physician and a member of the nursing staff. Considering these assessments combined with the history provided by the referring party, a care plan is then written and discussed with physical therapy and occupational therapy staff.
Each patient is then assigned a primary bedside nurse as well as a nursing case manager for his or her duration of stay, with no more than 3-4 patients being received by any one nurse, according to Kimberly Fetterolf, RN, chief clinical officer.
“When patients are admitted for complex wound care, there’s a team collaboration that results in individualized care planning for those wounds,” said Fetterolf, the first nurse manager ever appointed to the LTAC who’s been with Lourdes going on nine years. “Rehab services, respiratory care, nutrition specialists — everyone is involved in the planning of care, which promotes healing from an overall perspective. Even when it comes to social workers, they are extremely vested in the collaboration as well because they will know what will and won’t be feasible for particular patients in the home setting. Truly, everyone is involved.”
Once care plans are implemented they are only modified with input from each staff discipline, which meets as a team at least once weekly to discuss what the bedside nurses and physicians have concluded from daily rounds.
“There’s always communication between the staff and the physicians as to how to proceed with care, and each discipline sees each patient routinely,” said Mukalian, adding that if the situation calls for it, physicians will also provide care at the bedside while making their rounds.
“As physicians, we don’t just delegate for the sake of delegating,” he continued. “So when we know firsthand that a wound needs to be redressed based on how it looks that day, we’ll change the dressings directly when we’re with that patient. As surgeons, we make wounds so we have to take care of them as well.”
Wound Clinic Transfers
Care plans established in the LTAC are also discussed with the outpatient center when patients are being referred from the inpatient side. As with the protocol within the LTAC, the outpatient team will meet with Mukalian and inpatient providers to discuss treatment strategies and essentially continue with the already-proven-effective plan of care.
“In that capacity, when someone is discharged we’ve already put into place the plan that will be carried out in the next setting,” said Lendacky.
In most cases, Mukalian will be participating in the treatment in the outpatient clinic alongside Ruvolo, his staff, and Peterson, if there’s an existing infection. It’s also not unlikely that Ruvolo has already collaborated in care prior to LTAC discharge.
“The continuity is there,” Mukalian said. “The patients still have the same caretaker for their wounds whether they’re here or in the subacute center. And when they’re healthy enough, we get them back to their family physician.”
As Cowperthwait explains, the collaboration has impacted the rate in which patients would potentially later require short-term acute hospital readmission. As needed, a hyperbarics center that’s independent of the outpatient clinic is also onsite for infection treatment and wound closure.
“Essentially, we’ve taken the outpatient center and the hyperbarics center and created a consistency in care with the benefit of having access to inpatient care if it’s needed,” she continued. “So, we’re closing a loop there. Hypothetically, if patients were to go from a wound care center to the emergency room, then there’s also that chance of another admission to the short-term hospital. Outpatient centers and general hospitals do wonderful work, but we’re set up to provide more extensive services and we’re specifically staffed and trained to care for sicker people who are living with chronic, nonhealing wounds when these facilities and patients could use our help.”
Also owned by Lourdes, the hyperbarics center houses two chambers and sees more than 10 patients per day, said Doris Rivera, EMT, center manger. About 85 percent of patients are transferred from the outpatient side with the other 15 percent coming from the LTAC.
As the acuity of patients in this country becomes more severe as more people live with more chronic wounds, that 15 percent could very likely increase. However, with the adjustments the LTAC staff has made over its first nine years of existence, Cowperthwait is not alarmed.
“Let’s face it, 20 years ago, a lot of these patients who come here today and do well would not have survived,” she said. “And we’re constantly assessing and reassessing our processes in real time. There are a lot of intelligent people at the table here who are collaborating to put treatment plans in place for patients who have failed before coming to us. It really takes everybody working cohesively, intellectually, and with evidence-based processes to move these patients along. The commitment from everyone here has just been unbelievable.”
Joe Darrah is managing editor of Today’s Wound Clinic.