facilityinfocus - Today`s Wound Clinic

facilityinfocus
Creating a Collaborative
Wound Care Continuum
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Main Line Health’s outpatient program is progressively changing the face of
wound care throughout the hospital network.
By Joe Darrah
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ing wound care programs available in the
Philadelphia region.”
As she and her staff members attest,
it’s a program born out of a collaborative
effort to remain comprehensive in care,
reliant on the support of the interdisciplinary staff, dedicated to providing education and follow-up communication
with primary clinicians, and committed
to the processes put into place. It’s also
the result of a meticulous approach to
wound care that’s apparent even to the
extent of how the Bryn Mawr center was
originally mapped.
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THE WOUND TEAM: Members of Main Line Health’s wound care staff include (from
left): Mary Behler, RN; Rebecca Witham, MD; Sharon Lynn Hannum, RN; Jeannine
Sorenson, RN; Pam Beideman, RN; Debbie Raap, PCT; and Brenda Shantz, RN.
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cost-effective through the establishment
of a structured protocol that has since
begun to be implemented throughout
the hospital system’s reach along Philly’s
western suburbs into Paoli (PA) Hospital.
Predicated on a philosophy that utilizes a
multidisciplinary wound care staff jointly
trained on a collaborative procedural approach that allows consistent patient care,
product usage, and electronic health record (EHR) optimization within multiple facility sites, the program, as it nears
full integration, also allows patients to experience the same clinical and follow-up
services provided by the same healthcare
staff within the network — regardless of
where they receive care.
“It’s a superior patient experience,”
said Hannum, a wound care nurse of
nearly 20 years with an extensive background in formulating and operating
outpatient hospital wound departments
along the metro regions of Philadelphia,
New Jersey, and New York. “I honestly
think we have one of the best function-
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ryn Mawr, PA — Give her 90 days,
and Sharon Lynn Hannum, RN,
will tell you she can devise, design,
and launch a hospital-based outpatient
wound care center from the ground up.
Give her nine months, as did the administration at Main Line Health, one of suburban Philadelphia’s most comprehensive
hospital networks, and you get what you
bargain for — the foundation for a program that is systematically revamping
the structure and delivery of wound care
across the entire health system.
Recruited to the Main Line’s Bryn
Mawr (PA) Hospital in 2003 to establish
an outpatient wound-healing center at
the Magnet facility to target a local patient population predominantly being
treated in the primary care arena, Hannum’s center has met this accomplishment and then some.With a progressively
increasing patient caseload that has been
on the incline since the doors opened
(the center recorded 3,000 visits in 2012),
the wound care program has also proven
www.todayswoundclinic.com A Collaborative Blueprint
Laying out the plans for what would
eventually become a 3,600-square-foot
outpatient center took the intricate
consideration of determining where
entrances and exits should appear to allocating for an appropriate number
of examination rooms and having the
foresight to allot enough space for what
would become a busy hyperbarics suite
(which averages 3-4 patients per week
today), all of which Hannum played a
role in. With additional time afforded
to the opening of the wound center as
the hospital awaited the relocation of a
breast health center that had occupied
the wound center’s future space, Hannum had that much more opportunity to
“get her hands dirty.”
“We knew we would need enough
exam rooms so that patients wouldn’t
have to wait long in our reception area,”
she said. “It’s one thing to wait in a lobby, it’s another thing to have the access
to your own room to wait. If you only
have two exam rooms to offer and you
have four people scheduled in an hour’s
time, somebody’s going to be waiting at
reception for a while. I wanted to make
sure we designed a center that considToday’s Wound Clinic® April 2013
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facilityinfocus
Undergoing Wound Care, Together
Some “serendipitous” healthcare complications lead one Philadelphia-area couple into
neighboring hyperbaric chambers.
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By Joe Darrah
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Bryn Mawr, PA — Since
the day they met more than 60
years ago, the lives of Augustus
Michael (Gus) and Lee Iatesta
have, quite literally, been defined by coincidence. Recently,
Gus and Lee Iatesta
so too has their healthcare.
It was the spring of 1952 when Lee was approached by
her parents about a young doctor, the son of a couple they
knew through a local Sons of Italy club based in the Philadelphia suburbs, whom they wanted to introduce her to.
Already dating someone at the time, Lee wasn’t interested
in being set up, so she shrugged it off. Unbeknownst to
Gus, who just so happened to make an appearance at
a Sons of Italy dance on an otherwise uneventful Friday
night for he and a few friends that Lee was also at, he’d
end up introducing himself upon his arrival, asking her for
a dance. She obliged, and by the time Lee’s parents put
one and one together for her later that evening, she was
already smitten.
“It was just so coincidental that we met on our own like
that, but the rest is history, because I ended up taking him
to my junior and senior proms, and we married two years
later,” said Lee, who recently completed several weeks of
hyperbaric therapy at Bryn Mawr (PA) Hospital’s Wound
Healing Center due to a compromised bladder following
radiation treatment for cervical cancer. Having been previously recommended for hyperbaric treatments by his
urologist a few years prior after developing minor radiation
proctitis as a side effect to prostate cancer treatments,
Gus had been hesitant about undergoing the therapy.
With the proctitis condition doing little to impact his quality of life, he had decided against hyperbarics because of
the weeks-long commitment he was told it would take to
achieve full wound closure. However, when Lee was informed that hyperbarics was the only option she had to
close a hole in her bladder that registered the size of a
half dollar, Gus began to see the procedure in a new light.
“I figured, if my wife had to do it and I could benefit
from it, we might as well do it together,” he said. After
more than two months of treatment sessions, both are
fully healed.
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ered patient flow.”
With five exam rooms available (four for ambulatory patients,
one that’s big enough to house a stretcher), Bryn Mawr was
also designed to have the capacity to handle non-ambulatory
and non-emergency cases.
“One of the most important decisions we made when we
designed our center was to provide space for stretchers to come
in through a back entrance that leads right into our biggest
exam room,” Hannum said. “You might have someone come
in with a sacral or hip wound where they can’t be in a normal
exam chair, so having a bed and having the ability to open the
back door so stretchers don’t have to come through the waiting
room, where we often have obstacles like people in wheelchairs
or on crutches, makes things that much more convenient for
the patients and the staff.”
Another crucial logistical step taken during the design phase
was reserving space for dressing rooms for hyperbarics patients.
Originally operating with one chamber, the center added a
second (bariatric) chamber six months after opening, an upgrade Hannum said she anticipated but needed the patient visit
numbers to prove themselves in order to justify the acquisition.
“Knowing the amount of square footage we would need to
fit enough exam rooms and a hyperbaric area was very important,” Hannum continued. “You need to know where your
equipment is going before you get it.You need to know where
your furniture is going. Knowing we wanted to have more than
one hyperbaric chamber, we needed enough clothing rooms so
that patients could come in and change in privacy while we still
had patients in the chambers.”
Also not to be neglected was Hannum’s vision of the appropriate wound care staff, which includes a panel of eight physicians from a multitude of specialties including podiatry, general
surgery (see sidebar on page 42), internal medicine, plastics,
and vascular care as well as a nursing staff that today has grown
to seven members among the Bryn Mawr and Paoli centers.
One of the first clinicians to volunteer for a position within
the outpatient center was Daniel Westawski, MD, FACS, a plastic surgeon who had already been on staff in Bryn Mawr’s inpatient wound department at the time the outpatient center began construction.Though he stands by the wound care that had
traditionally been performed at the hospital, Westawski, who
also owns three private practices within the outlying region,
admits that the need for a devoted outpatient center was real
and that the challenge to give patients the dedicated, specialized care they deserved had become too daunting.
“Before the outpatient center opened, everyone, including
internal medicine and general surgeons, would try to manage
wounds on their own,” he related. “They’d call in plastic surgeons like myself to assist, but that was hard to do from a private
practice standpoint because wound patients specifically require
a lot of care and follow up. They require a lot of medical resources and a lot of time that, in private practice — no matter
the specialty — you’re just not typically equipped to do to the
degree you need to.”
However, securing the trust of area physicians to send their
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Road to Recovery
Prior to the hyperbaric treatments, Lee’s condition had
become very severe. Saddled with catheters on each kidney, her bladder would not function on its own and life had
become very painful, not to mention uncomfortable. She
April 2013 Today’s Wound Clinic®
www.todayswoundclinic.com
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Although the outpatient center had patients essentially waiting in the wings due to referrals coming from its own physician staff members such as
Westawski and Robert C. Floros, DPM, a podiatrist
who also owns multiple private practices in the region who previously worked with Hannum prior to
joining Bryn Mawr in 2003, establishing a reputation as a referral center would take some time as well
as a delicate political approach.
“Even when considering that making referrals
would be a way to defray costs for primary providers and that many of them don’t have the staff to
handle wound care patients coming into their offices on a weekly basis or the inventory of supplies
required to manage chronic wounds, some of the
area physicians were a little leery of us at the beginning — they didn’t want to ‘lose’ their patients
to us,” Hannum said.
As a referring physician himself, Westawski
said earning the physicians’ trust and their referrals came down to initiating communication with
each provider to inform them about the structure
and benefits of their services as well as their intentions to keep an open line of communication
regarding all aspects of wound care that could impact other comorbidities.
“And by doing that we’ve been very well received
in our community,” Westawski said. “The providers
are happy to work with us as a team because we
make sure we collaborate with them frequently by
asking for their help in managing the patients’ overall health, particularly related to diabetes, congestive
heart failure, or chronic renal deficiencies, while
we’re trying to get their wound closed. Even before
something as simple as a lymphedema pump, we’ll
check with the patient’s cardiologist to make sure it’s
not going to cause unforeseen stress on their heart.
These physicians don’t want their patients needing
more healing time than necessary.And we have a coordinated team of clinicians that referring physicians
know have the time to devote to their patients.”
underwent surgery in an attempt to repair her damaged bladder, but
due to her age and radiation treatments, the bladder wall had become
too thin to seal. Sensing how fearful Lee had become from the multiple
procedures and the lengthy hyperbaric regimen she would need to undergo, Gus didn’t want her to go through anything alone. They were
both relieved to learn that the wound care center at Bryn Mawr, less
than a 20-minute commute from their home in Broomall, PA, could not
only treat them both but allow them to do so side-by-side in neighboring chambers. For more than two months the couple spent the middle
of their afternoons together in the wound center. Though Lee’s 40 prescribed treatments outnumbered Gus’ required 35, he’d accompany
her through the duration of her visits — often spending some downtime getting to know their caregivers better.
“It was one of those serendipitous things that you can’t say you ‘enjoyed’ doing, but it was nice to be able to support each other,” said Gus,
a retired optometrist who also underwent open-heart surgery this past
July for an aortic valve replacement and two bypasses (as well as the
subsequent cardiac rehabilitation, which frequently overlapped with his
hyperbaric therapy). “The care we received exceeded our expectations.
We got to know all the physicians and all the staff, and everyone was
very courteous — we had absolutely a completely positive experience.”
The couple know a bit about serendipity. Aside from how they met,
their daughter met her husband, a Frenchman, while working at a
convention in New Orleans several years ago. She, a manager for a
company that operates national medical conventions and he, an engineer who was visiting the US in hopes of securing a research grant,
didn’t have much time to get acquainted before he had to return home.
However, when that grant ultimately came through from Philadelphia’s
Drexel University, the two had a chance to reconnect. Today, they’re
married, living in France, and the Iatestas can say they have five bilingual grandchildren.
“After the initial shock of her moving,” Lee said, “I told myself she
could just as easily have met someone from Iowa or Illinois and moved
there; but I’d much rather land in Paris and see the Eiffel Tower when
I go to visit her.”
With their health back on the mend, frequent travel has again become part of life for the Iatestas, whose regular travels have also seen
them visit Italy, Spain, Sardinia, the Caribbean Islands, China, Singapore, and Iceland. Speaking with Today’s Wound Clinic on the heels
of Lee’s most recent urologist visit in early March, the couple was
ready to celebrate her recent clean bill of health. Their plans for spring
included an annual trip to Florida, where they’ll spend several weeks
enjoying each other’s company, relaxing, and maybe taking in a movie
or two together outside the confines of a hyperbaric chamber.
“It’s been a tough year, health-wise,” Gus said. “Hopefully, we’ll
have some time out of the hospital now for a while.” n
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Reliance on Referrals
Wound Care Patient Profile (continued)
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patients into the Bryn Mawr center would not be
as easy as anticipated.
Coordinated Collaboration
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That team, aside from being comprised of specialists who represent a wide range across the healthcare
spectrum, is know for the depths of experience that
it collectively possesses, especially as it pertains to wound care. Floros, a fellow of the American College of Foot and Ankle Surgeons
who has spent nearly 30 years in podiatric practice, has been providing wound care, as he puts it, “since before it became popular.”
“In our field of foot and ankle reconstruction, we’ve been providing wound care since day one,” said Floros, who’s spent the last
20 years of his career specializing in wound care. “I refer my patients here directly. The excellence and quality of the care here
is something that I’ve never seen in my 28 years of experience. It’s just tremendous.”
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April 2013 Today’s Wound Clinic®
www.todayswoundclinic.com
facilityinfocus
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Forced into permanent US
residency due to civil unrest back
home, an Iranian physician joins
the wound care ‘revolution.’
By Joe Darrah
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Bryn Mawr, PA
— Upon leaving his
native Persia for the
US in the mid-1970s,
Manoucher Afshari,
MD, FICS, FACS, had
Manoucher Afshari,
his career, his life all
MD, FICS, FACS
mapped out. Having
already earned his professional doctorate in medicine, he wanted to do the
same in the US and bring that knowledge and skills back home.
But as he finished his education at
the turn of the new decade, the Iranian
Revolution was in full swing — political and social unrest posing threats to
safety. At the urging of his family, he
decided to “keep his distance for a few
months.” Twenty-three years later,
he’s still here, carving out an extensive healthcare career that recently
led him into wound care, which has
also seen great change in the time
since Afshari entered this country.
“After about three years went by
and home was still the same with chaos, I had to look around at my children
growing and realize that this is where
me and my family were staying,” said
Afshari, one of eight physicians at
Bryn Mawr (PA) Hospital’s Wound
Healing Center. “I am very thankful
and fortunate to be here still.”
Putting off random urges to retire
over the years, he’s proven to be an
asset to the outpatient wound program at Bryn Mawr due to an extensive
healthcare background that he said
greatly lends to the care of his patients.
A member of the Bryn Mawr staff
since October, Afshari spent more
than eight years in residency during the
1980s, including general surgery, trauma surgery, cardiac surgery, and kidney
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Future Expansion
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A Global Wound Care
Perspective
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a proven wound-healing and hyperbaric
program that’s expanding throughout
the system.”
The enhanced service at the Paoli site
have long been realized, according to Pamela Beideman, RN, a wound care nurse
on staff at Paoli who has been with the
hospital 28 years (the last seven specifically in wound care). While correlation has
always existed between the two centers,
Beideman said the impact of the official
merger has been significant.
“It’s more uniform today — we utilize
staff between the two units and coordinate
our educational programs, patient care,
and products being used,” said Beideman,
whose extensive healthcare background
includes med/surg, oncology, gastrointestinal, outpatient surgery, endoscopy, and
critical care. “There’s more continuity
between the units, so patients are able to
have a more pleasant experience if they
need to visit both locations.”
Not only has the ability for patients to
undergo care simultaneously become a
possibility, it has become reality for many
patients within the system, Beideman said.
“We encourage our patients to accommodate whatever their schedules may be
by receiving treatment at multiple centers so that there’s no break in their treatment,” she said.
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Like Westawski, Floros assisted in the
opening of the Bryn Mawr center, up to
and including his involvement in the ordering of supplies and equipment.With his
surgical background, he’s often brought in
to consult on any wound below the knee,
which makes up an estimated 60 percent
of the program’s population. He said the
collaboration between physicians and
nurses begins prior to the initiation of any
care planning.
“We’ll talk amongst each other about
the diagnosis of the systemic disease that
might be causing the wound or the trauma that might have caused it, and deal
with the ramifications of that — whether
it’s malignment, or the need for fusion
or debridement and wound healing, or
helping with referrals and establishing the
network and team concept with the vascular specialist, neurologist, plastics, internal medicine or renal,” Floros said. “After
a patient has been examined and we’ve
determined as a team the diagnosis and
reason for their wound, we’ll plug them
into the specialties they need. There’s a
lot of referral in the system, and the collaboration between our center and other
specialists has really helped our patients
tremendously as far as exponentially
improving healing rates and the success
rate in reducing amputations. It’s a nice
luxury for patients to have in the system.”
(See patient sidebar on page 37).
Beyond open communication, the staff
utilizes an EHR system that was implemented in 2012 and has become uniform
within multiple Main Line locations.
Based on the progress experienced at
Bryn Mawr, Hannum was approached by
health system administration to oversee
the wound care program at Paoli.
“It was a great opportunity for me
to foster collaboration, peer review, and
coverage amongst both sites,” said Hannum, referring to a peer-review process
she enacted at both sites that helps ensure
protocol is carried out consistently at all
times — even to the point that registration remains accurate and that all pertinent patient information is collected prior to clinical assessment. “We took what
was working at Bryn Mawr and came to
Paoli with it, and we began to realize that
we’re not just silos in a system — we’re
In preparation for the wound care
program’s expansion across Main Line
Health, Hannum has started forming an
affinity wound care group that’s responsible for meeting regularly to evaluate
products, policies, and procedures as expansion progresses.
“If you’re not collaborating, you’re missing out on the sharing of ideas, sharing of
supplies — just the general cohesion of
policies, protocol, and patient care,” Hannum said. “For the patient’s peace of mind
and potential for better outcomes — it
just makes more sense. Our patients can
feel confident and comfortable that there’s
always someone here to care for them
who has the knowledge and information
related to their care in particular.” n
Joe Darrah is managing editor of Today’s
Wound Clinic.
April 2013 Today’s Wound Clinic®
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www.todayswoundclinic.com
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classified
contiuned from page 42
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Elizabethtown, KY MANAGER, WOUND CARE/VASCULAR CENTER IC
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JOB SUMMARY: This position is responsible and accountable for daily operations of the Wound Care and Hyperbaric Medicine Center and the Vascular Center to include fiscal and resource management. Develops/implements processes to facilitate timely patient throughput for Wound Care and Vascular Center patients and maximize utilization of rooms and time. Schedules patients appropriately, working in collaboration with referral sources to maximize efficiencies. Collects and analyzes data to ensure targets are met. Assists in marketing the (WCHMC) to physicians and the community within the service area. Maintains open communication and professional relationships with members of the medical staff. QUALIFICATIONS: Current unrestricted license, as a RN in Kentucky required. Successful completion of an approved/accredited hyperbaric medicine training course within 60 days of hire required. Certification as a Certified Hyperbaric Technician (CHT) or Certified Hyperbaric Registered Nurse (CHRN) within 18 months of hire required. Minimum of 5 years of recent clinical experience, two years of wound specialty experience required. BLS certification within 90 days of hire required. BS in nursing or related field required. Management/supervisory experience preferred. Wound Care Certification by the Wound Ostomy Continence Nursing Certification Board preferred. Must be able to multitask. Must have commitment to customer service. Must be familiar with CMS and Joint Commission regulations. Please visit our website to learn more about our wound care facility at: http://www.hmh.net/hmhwebsite/Location.aspx?P
ageID=11. Contact: Lisa Miller or Julianne Hart, Coordinators, Recruitment/Retention (270) 706-­‐1762 or (270) 706-­‐1613 Email: [email protected] or [email protected] Visit us on the web at www.hmh.net to apply and submit resume. Here To Stay
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transplant surgery. In order to maintain a valid visa during this time,
Afshari said he had to remain “in training,” so he kept broadening
his scope of practice.
in the United Sates and
“At that point I was determined to stay
learn as much as I could, even if that meant that I would ‘retire’ one
day as a resident,” he said, somewhat in jest. “I came to the US
because I wanted to be a surgeon, and this was and still is the best
place to learn how to practice medicine.”
At the age of 40 in 1982, he opened his own general and vascular surgery practice while working as a trauma surgeon. He’d
do so for 10 years before relocating north to Maine in the early
2000s during a time in Pennsylvania when many physicians closed
or relocated their practices due to high insurance costs. Further
expanding on his skills in the “Pine Tree State,” Afshari spent eight
years practicing as a general surgeon in a rural, 15-bed hospital.
The more patients he began to care for who lived with chronic,
nonhealing wounds, the more his interest in specializing in this field
became piqued.
Today, he’s a fellow of the American and International College
of Surgeons and serves as clinical associate professor at Temple
University in Philadelphia, where he instructs residents and medical
students. His curriculum includes wound care, which he said he
continues to gain an increased appreciation for.
“In general surgery, you know certain physiology of wounds but
you don’t always realize how much a wound center can help your
patients heal their wounds,” he explained. “When you’re talking
about patients who’ve had wounds for many years, something’s
missing in their overall care and their health. So I’ve tried to bring
my expertise and combine it with treatments that we use in the
wound center to help our patients heal.”
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At Bryn Mawr, Afshari works among an interdisciplinary physician and nursing wound care staff that includes podiatry, general
surgery, internal medicine, plastics, and vascular care.
Through a care philosophy that stresses collaboration and a uniform protocol that has been clearly defined and implemented into
a universal electronic health record, Afshari and his colleagues are
changing the way wound care is conducted for many people living
in Philadelphia and its surrounding suburbs.
Launched in 2003, the wound-healing program at Bryn Mawr has
since extended into the company’s Paoli (PA) Hospital. Afshari said
the collaboration within the wound program serves as the basis for
the improved wound healing and amputation rates that the network
is seeing.
“There’s harmony in this system; we work together — that’s the
only way to do it,” he said. “A lot of hospitals today want to open
their own wound centers, but you have to be willing to standardize
your care and hold yourself to a very high standard.”
“At the start of my career, there were no wound centers,” he
continued. “But wounds have always been ‘wounds’ — whether
they’re due to diabetes, atherosclerosis, infection, trauma, war,
whatever. The only thing different today is the way that we treat
them. We understand more of the philosophy behind what heals
wounds and how to better care for patients.” n
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