Transcript Wound Management - Harvard Skin Disease Research Center

Dermatology Wound Clinic
Jessica Scanlon, MD
October 9, 2014
Who We Are
• Physicians
– Vince Li
– Jessica Scanlon
– Bill Tsiaras
• Jen Elliott, PA-C
• Nursing staff
– MAs: Koravee, Tina
– Triage: Mary
– Scheduling: Janelle Trotman (used to be DaLisa)
What We Do
• Management of chronic wounds
– Wounds lasting longer than 6 weeks
– Frequent wounds
– Pts with a history of chronic wounds
– Complex wounds
Conditions We Treat
• The 3 big chronic wounds:
– Venous leg ulcers
– Diabetic foot ulcers
– Arterial ulcers
• Complex dermatologic conditions
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Pyoderma gangrenosum
Morphea
Radiation dermatitis
Vasculitis
Infection
NLD
Calciphylaxis
Tumors
Etc…
What We See
Chronic Wounds
• Wound management is complex
• Requires frequent wound and dressing
reassessment
How Do We Operate
• Team approach
– Everyone has an important role in wound care
• Important team players
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Patients: Age, comorbidities, ability to manage ADLs
Families, friends: Complicated and complicating
VNA, home health aides, hospice care
Other wound centers
PCPs, other specialties (vascular, plastics, ortho, onc)
Dermatology: Office manager, MAs, triage, PA, MDs
Managing Comorbidities
• A chronic wound is a systemic disease – affected by a host of other factors
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Chronic disease
Venous and/or arterial insufficiency
Diabetes
Neurologic defects
Psychiatric disturbance
Immunodeficiency
Nutritional deficiency
Medications
Blood disorders, hypercoagulability
Advanced age
Allergy
Pressure, infection, edema
Smoking, alcohol, illicit drugs
Others…
Managing Pt Expectations
• Ulcers have a big impact on QOL
– Pain
– Activity level, mobility
– Time of dressing changes
– Pt’s rely more heavily on others
– Showering, swimming
• Pt’s expect ulcers to heal quickly, painlessly,
and with a minimum of trouble
Choosing Appropriate Wound
Dressings
• Assessment of the wound/milieu
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Moisture balance
Inflammation
Necrotic debris, crusting
Bacterial bioburden (odor, drainage)
Quality of the skin (ACD, xerosis, stasis, etc)
• Comorbid factors
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Ease of dressing changes
Pain
Is the person changing the dressings making things worse?
Dressing availability, cost
Tools
• Dressings
• Debridement
– Sharp debridement, collagenase
• Compression
• Topical agents
– Regranex
• Bio-Engineered Grafts
– OASIS, Apligraf, Dermagraft, EpiFix
• Antiseptic measures
Maintaining the Moisture Balance
Tegaderm
(film)
Duoderm
(hydrocolloid)
Aquacel
(hydrofiber)
Allevyn foam
cavity
dressing
(foam)
Antiseptic Dressings
Compression
Wound Clinic
• Dressings taken down, wound cleaned with NS
• EMLA – 15 minutes
• Pt is evaluated, wound assessed
– Measure the wound
– Debridement
– Cultures
– Skin substitute if necessary
– Wounds redressed
Wound Clinic
• Much of the work is done outside of clinic, by support
staff
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PA’s, communicating with pharmacies
Communicating with VNA or other wound care providers
Managing supplies, compression pumps
Ordering skin substitutes and obtaining them from the
blood bank
Providing OTC wound supply resources
Managing cultures, biopsy results, labs
Managing billing issues
Managing pt concerns and expectations
Care Coordination
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VNA services
Medical supply ordering
HBOT
Medication/Dressing PAs
– Regranex, collagenase, grafts
• Physical therapy services
– Lymphedema massage
• Equipment
– Wound VAC
– Compression boots
• Referrals
– Vascular
– Plastics
– Renal, other medicine services
Logistics
• Scheduling
– Urgent issues
– All others go through our scheduler
• Days
– Thursdays AM/PM, Vince monthly
– Bill Wednesdays
• Location
– 221 Longwood
• Inpatient consult service