Taking a Psychosocial Approach to Wound Care at Orlando Health

  Orlando, FL — It was meant as an innocent question, really, when Suzanne Roach asked her physician about the softball-sized mass within her left thigh. The impetus for her visit to the doctor that day in the fall of 2013 wasn’t even related to that lump, which she said never affected her gait nor could even be considered a nuisance — it was just something she had noticed. Instead, she simply had scheduled a visit with the family physician in her hometown of Conneaut Lake, PA, during a trip back home because she needed a refill on Prednisone for a pyoderma gangrenosum condition diagnosed in 2008.

   “I was getting ready to leave when he asked, ‘Do you have any questions?’ so I rolled my pant leg up and, kind of jokingly asked, ‘This isn’t cancer, is it?’”

  Upon feeling the surface, the physician thought not. Assuming it was a lipoma due to its “soft consistency” that “could be moved around,” he instructed Roach, 36, to monitor the situation and seek consultation if the mass continued to grow and/or became painful.

  Within a few months the area began to ache, so Roach decided to see an orthopedic surgeon who ordered an MRI that was inconclusive, so she was referred to an orthopedic oncologist for biopsy. On Feb. 18, 2013, she got a diagnosis that only months prior she had broached in such tongue-in-cheek fashion: cancer; specifically myxoid liposarcoma, a rare soft-tissue tumor that rooted in her femur and is actually known for its misleading benign appearance and likely to be a suspected lipoma, according to literature.

   “And here I thought I was just going to need a quick surgery to have it removed,” said Roach, who recently met with Today’s Wound Clinic during our visit to the Orlando Health Wound Healing Center, a member of the Orlando Health network.

  Today, Roach is cancer free after removal of the tumor last spring, which followed three months of relatively unsuccessful chemotherapy; but she has since required wound care for a number of surgical wounds that have proven difficult to close (and keep clean of infections) that have developed due to the comorbid gangrenosum — which may have initially gone underappreciated for its ability to impede postsurgical wound healing — before she was ultimately referred to the Orlando Health clinic. Despite the relief and joy that accompanies a successful “fight” against cancer, Roach has endured emotional and mental challenges as a result of needing multiple operations to repair not just the wound at the initial point of surgical entry, but subsequent donor site and flap repairs that were needed to heal the original wound, which would develop a MRSA infection that threatened amputation of the left leg not too long ago.

   “I don’t know if the underlying pathophysiology with the pyoderma gangrenosum was completely being addressed, knowing that she was a high risk for graft and flap failure,” said Walter A. Conlan III, MD, CWSP, medical director of the wound center, a multidisciplinary facility that features a host of allied health services, including what physicians and nurses label as a psychosocial approach to wound care for patients, who often face extreme circumstances beyond their wounds, such as Roach.

   “If someone loses their leg, that’s going to have an obvious impact on one’s mental and emotional state,” said Conlan, who helped launch the wound center in 2012 along with Karen Durigan, BSN, RN, WOCN, MBA, CNML, nursing operations manager. “There can be a lot of anxiety and depression associated with that. Our goals here are to institute measures so that people can get back to work or back to whatever it is that helps them to be happy and productive in their lives while they’re with us — even before they actually heal their physical wounds.”

Psychosocially Speaking

  When Conlan and Durigan were granted the opportunity to develop a new outpatient center in Orlando by hospital administration, they weren’t shy about communicating the methodology they considered to be an optimal center for care.

   “We created a wish list for what we ‘could’ have based on the appropriate wound center that we envisioned,” said Conlan, who joined the organization in 1996 as a staff physician and was named medical director for a now defunct outpatient clinic that previously operated in conjunction with inpatient wound care for a decade before being resurrected when demand among many providers within the network remained overwhelming. “And we really placed an emphasis on instituting a multidisciplinary staff as well as hyperbaric oxygen therapy (HBOT) services so that we could lend to the treatment of advanced wound care,” he continued. “We have providers from among different disciplines such as plastic surgery, foot and ankle surgery, and infectious disease, which allows us to ‘cross-talk’ and heal a wide variety of wounds.”

  Among the physician group is Nicholas Bagnoli, DO, a physiatrist who assures that the physical rehabilitation of a wound care patient is not possible without addressing any underlying and/or apparent mental health issues.

   “The psychosocial element is a huge component to what we do here,” Bagnoli said. “A great majority of our patients are going to be looking at limb salvage (see “Limb-Salvage Program Growing at Wound Clinic”). They’ve likely been through the ‘gamut’: They’ve had vascular surgery, podiatry, infectious disease, physical therapy — all that can be done physically. But once they get here, we’re expected to be that opportunity for them to salvage their limb and not have to pursue on to an amputation. And that can be very stressful.”

  Roach not only had to contend with infection and additional surgeries to close the nonhealing surgical wound, she had to accept that her treatment at the wound clinic was her “last attempt” at limb preservation, according to Conlan and Alena Klochko, MD, the clinic’s infectious disease specialist to whom Roach was referred for inpatient care after months of post-cancer wound complications following surgery.

   “She’s a patient who’s diagnosed with a tumor to the lower extremity, and it’s believed to be resected successfully, and all should be ok; but then she’s referred for the inpatient rehab program because she’s having healing issues,” Bagnoli related. “We have her discharged home, but within a day or two she has difficulty climbing the stairs and returns to the hospital for another admission and further surgical intervention. She’s then referred to the outpatient clinic to participate in HBOT treatment and advanced wound care, but by that point she’s expectedly [stressed out.]”

  Someone who considers herself to be strong-willed and optimistic, Roach said the education and instruction she received at the clinic regarding her wound and her overall health slowly began to make a positive impact on her psyche as her wounds progressed. Placed on vacuum therapy for about five months, Roach had just completed her 40th and final HBOT dive at the time of TWC’s visit to the center and had been deemed infection free as well. Still using the assistance of a wheelchair and walker, her prognosis is full recovery.

   “I knew everyone here was giving everything that they had for me, so every time I came in for dressing changes I would try to watch everything that was being done, and I was given instruction to mimic everything done at home to avoid infection,” Roach said. “I just tried to stay positive because there’s only so much you can do.”

Extensive Service Lines

  When a referral for mental health services is required, referrals that Conlan described as “very rarely” needed at the center, contact with the patient’s primary care provider is initiated.

   “When there’s a life-threatening condition and a wound associated with it, when you heal the wound it can set up a lot of positive things because patients see that they can heal,” Conlan said. “But everyone’s different, and to some people diabetes will be just as devastating as a cancer diagnosis. And the No. 1 cause of amputations in the United States is from diabetic foot ulcers. So you can’t rule out potential referral.”

  While any life-threatening and chronic comorbid condition is sure to be associated with mental health concerns when it comes to wound patients, ostomy care continues to be a more specific link, according to Durigan, a nurse who possesses more than 30 years of inpatient and outpatient wound care experience. That said, when she was planning for the new outpatient setting a few years ago, Durigan knew she wanted to have ample space available for this additional niche population.

  Today, the ostomy clinic within the wound center sees an average of five patients per day. Previously housed in the main hospital, the clinic also cares for enterocutaneous fistula patients who have challenging abdominal wounds that require creative pouching.

   “It’s a service that we’ve always felt is very important to have because once patients leave us from the hospital they may feel like they’re on their own,” Durigan said. “Some patients may have to live with their stoma the rest of their lives, and a lot of these patients may have needs from a psychological standpoint. So it’s imperative that we make sure they can help themselves and that they know where they can get their supplies and where they can get help in general.”

  The wound center also contains an infusion center, which has been a great mesh for the facility because of the infectious disease patients seen on-site.

   “If someone needs something right away, such as IV antibiotics, we have them down the hall to start any necessary infusions,” said Durigan, who along with Conlan has played a large role in the “re-engineering” of the wound care landscape at the hospital, a Level I trauma center that will often see emergency department patients referred directly to the wound center following discharge. In fact, the wound center is located in the very space the hospital’s ED once occupied prior to a recent relocation. The setting has been ideal, according to Durigan.

   “When I was asked about the potential to move into this space, I knew it was perfect,” she continued. “We’ve got big corridors, and we were really looking for a place to incorporate the HBOT. So we eliminated some of the smaller exam rooms that had been here for the fast track area and gutted everything. We put down a new floor to make things more inviting, and we really only needed to ‘patch and paint.’ I had the nurse’s station redone and we’ve repurposed the old lounge into a conference room where we can eat and hold meetings and educational inservices. It’s very staff friendly and is a great place for them to be able to interact.”

  The staff includes a physician panel of eight members as well a team of 10 nurses and technicians.

  Gary Chessman, DPM, FACFAS, podiatric physician and surgeon, who has been with the organization 20 years, stressed the integration of the panel and staff as a whole as the most important means to the success of the new clinic.

   “I’m just elated that I’m here and we’re here to participate in the care of these patients’ lives the way that we are,” he said. “We’re very lucky to have the staff that we have; it’s a very intelligent group. At the end of the day the difference that we make in every single person’s life here — it’s remarkable. Wound care is not easy, but we’re making it easier.”

Limb-Salvage Program Growing at Wound Clinic

  Walter A. Conlan III, MD, CWSP, medical director of the Orlando Health Wound Healing Center, has long been aware of the demand for his newly launched facility.

   “There was already a needed service that crosses a wide array of medical specialties at the time we opened our center in 2012, and there were many physicians from different areas of care, from orthopedics and oncology to primary care and infectious disease, who wanted to have a center to send patients to get tertiary care for their wounds,” he said. “But what we’re really looking to do is solidify and build a limb-preservation program that will allow us to further decrease the number of amputations in the community.”

   As he and his staff continue to expand their impact on patient health, Conlan realizes that success will be determined by how many limbs they can preserve and how effectively they communicate their achievements not just with area physicians but directly to the members of the community themselves.

   To accomplish as much, Conlan is personally taking opportunities to visit providers and residents of local healthcare institutions to educate whoever is willing to listen about the advantages of dedicated wound care services.

   “We’re also focusing on building continuity between inpatient and outpatient care,” he explained. “We want to ensure that every patient discharged from this hospital and other area hospitals has appropriate follow up with the wound clinic to have that standard of care for different kinds of wounds they’re living with.”

   With a multidisciplinary staff that consists of an eight-member physician panel, wound-certified nurses, and hyperbaric technicians, the facility is already improving on amputation rates, according to Gary Chessman, DPM, FACFAS, podiatric physician and surgeon.

   “The number of amputations we’ve reduced for patients has radically changed in this community,” Chessman said. “What makes limb salvage so special is the orchestration of all the specialties involved. We in the wound care industry have all become better at the ‘working together’ part. It’s the integration and the communication that allows everybody’s therapy to dovetail. And when that occurs it’s a beautiful thing.”

Pediatric Specialists Healing Young Wound Patients in Florida

   In many ways, Jordan Brown behaves as a typical kid. He likes to play outside with his toy trucks and he recently became interested in youth soccer and hockey. But when a persistent fever would not subside after a few days of over-the-counter medications, his mother decided this was not “normal.” Not even for a 6-year-old boy who lives with spina bifida who has become accustomed to the occasional fever associated with urinary tract infections (UTIs).

   “But we couldn’t confirm [UTI] this time around because he was getting so dehydrated from having such a high fever,” said his mother, Jennifer Brown, 43, of Orlando, FL. “He was put on a very low dose of antibiotics as a precaution, but things did not get any better.”

   Though Jennifer had already become quite familiar with caring for her son’s medical needs over the years, she remained equally concerned and puzzled about Jordan as a few days passed and the fever raged on to temperatures higher than 102. Retracing her and his steps as meticulously as she could, she didn’t suspect a simple knee scrape that he had experienced about a week earlier could have any link. But when she removed the bandage she had applied before bathing him one evening, she noticed that the cut had developed into a cyst-like growth that had burst. His leg was red and hot to the touch; she went straight to the emergency department at Arnold Palmer Hospital for Children, a member of the Orlando Health network.

   “The cut was down to the bone and had a bad case of cellulitis from mid-thigh to mid-calf that was a result of a staph and strep infection in his knee,” she explained.

   Hospitalized five days for IV antibiotic treatment, Jordan would be referred to the Orlando Health Wound Healing Center, where he would continue treatment with Alena Klochko, MD, an infectious disease specialist and member of the wound clinic’s eight-member physician panel. Healed within three months’ time and discharged with oral antibiotics, Jordan would soon display similar skin symptoms at home along the upper thigh of the same leg — symptoms that Jennifer was much more attuned to — and was back in the hospital, diagnosed with a presumed unrelated fungal infection within his femur. Unfortunately located along a portion of his leg susceptible to friction as a result of the way he ambulates (paralyzed from the waist down, Jordan moves by crawling and dragging his legs when not using his wheelchair), the wound has remained tough to heal more than one year later — though at last measurement it had been reduced to less than 1 cm.

   Still, her son’s experience has been nothing short of remarkable, Jennifer said, thanks in large part to Klochko and the nursing staff at the wound clinic.

   “They are like our family in a lot of ways,” she said. “There will actually be some sadness when we leave here.”

A Mother & Son’s Journey

   Initially requiring daily wound center visits to avoid recurrent infection, Jordan has seen his time reduced to twice weekly and, presently, once weekly as the wound, which has required Jennifer to be his caregiver at home in a way that even she had a tough time getting used to, has been reduced.

   “It really took about a month before I actually did anything myself at home with him,” she related. “Once I started cleaning it, I became more comfortable with it. We were sponge-bathing for a long time, but now we have a removable shower head and bench in place so that we can at least get the ‘6-year-old-boy dirt’ off him more easily.”

   Other adjustments have also come in time. His previous wound care hospitalizations caused Jordan to repeat kindergarten and receive homeschooling for a time, but a specialty designed orthotic clamshell brace (Hanger® Clinic) that he now wears allows him to attend school and be considered for wheelchair-assisted sports. It also provides Jennifer with some peace of mind.

   “It’s healing, so it makes me feel like I’m doing a good job,” she said. “If something doesn’t look right, I contact the wound clinic staff and they’re always available. I have cell phone numbers — it’s just been fantastic.”

   The wound has not been quite as easy to get used to for his providers, who say it’s one of the more difficult cases they’ve cared for at the center.

   “It’s a wound that’s a combination of neuropathic, traumatic, and pressure related, said Klochko, who along with Karen Durigan, BSN, RN, WOCN, MBA, CNML, nursing operations manager, and other staff members represents a rare breed of pediatric-specialty providers on staff within an outpatient wound clinic. “It’s been one of the most complicated wounds we’ve had to manage here.”

   With the luxury of having experienced pediatric providers within the existing wound center, Klochko said it was an easy decision to transition wound care from the children’s hospital into the outpatient setting based on the availability of not just more space and products devoted strictly to advanced care but a provider group that could commit its time solely to wound care as well. It’s not much different than the rationale behind the setting being more appropriate from the perspective of a primary care provider or skilled nursing facility in that regard. Still, it’s not an available service that every hospital-based wound center can take advantage of to this extent.

   “I think that’s something very unique we offer here,” Klochko said. “We feel that we’re filling a gap that is for the most part difficult to fill.”

   Jordan is not yet at the point where he can safely play in the sandbox or get into a swimming pool, but Mom says he’s learning to deal with the clinic visits as well as the routine hospital rendezvous he’s required to conduct for the spina bifida care. He’s had several castings and surgeries to date, such as two Achilles releases, shunt, spinal closing, and hernia removal necessitated by the weight distribution to his abdomen that occurred as he learned to crawl. He’ll also require additional spinal procedures as he grows up, but aside from having to spend his last couple birthdays within the confines of a healthcare setting (the wound clinic threw him an impromptu party last year), he may one day only have to show a minuscule scar on his knee for all his wound care troubles.

   “He calls it his ‘football’ leg because the stitch marks from the sutures resemble the laces of a football,” Jennifer said. “Going to the hospital is really hard for him because he knows he’s going to get ‘poked,’ and that’s his No. 1 fear. But once the ‘pokey,’ as we call it is in, he’s fine. He actually looks forward to wound care because they all treat him like their own.”

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

To view photos from our trip to Orlando Health, visit https://www.todayswoundclinic.com/slideshow/facility-focus-photo-slideshow-taking-psychosocial-approach-wound-care-orlando-health