The “Rapid Track” to Improved Wound Outcomes

  There may not be anything more indicative of the frailties that exist in today’s healthcare system than the continued overcrowding of emergency departments across the US. As Americans live older with chronic health conditions, the wound care industry specifically is becoming more affected. According to Nawar et al, more than 11 million visits for wound-related issues occurred in EDs throughout the US in 2005.¹   The result of a variety of circumstances (ie, a large uninsured/underinsured population, a lack of access to healthcare specialists such as wound care providers, a lagging economy coupled with high costs for medical care), the burden placed on EDs in this country is exemplified by the number of patients who seek care in the ED for services that should be conducted in a dedicated specialty clinic — including wound care.   Aside from a backlog that gets created when large crowds present in a facility’s ED, patients also face the risk of receiving inappropriate treatments when well-intentioned providers become too pressed for time and often turn to prescribing systemic antibiotics to treat common maladies. In 2009, ED visits in the US exceeded 136 million people,² and as much as 20 percent of all medical malpractice claims (and more than 10 percent of all malpractice settlements) have stemmed from clinical issues that are associated with wound care.³   While wounds that are associated with acute injuries often require an initial ED visit, non-acute wounds and skin infections are better served by early access to a wound care specialist (WCS). ED visits are typically managed by different providers, which results in fragmented care when patients return to the hospital for recurrent conditions.   An awareness of this problem has led to a unique program for wound care patients at the University of Mississippi Medical Center (UMMC), Jackson, MS, which serves as the only academic medical center in a state that’s dealing with great health disparities, high disease and mortality rates, and a large portion of its population being considered low socioeconomic status. Through the utilization of the new initiative, UMMC has reduced its traffic within the ED while improving outcomes and streamlining wound-specific care more efficiently in its outpatient center, eliminating the need for patients to make multiple visits.   The “Rapid Track for Minor Care” was launched in May 2011 as a means to provide non-urgent treatment in a dedicated area of the ED for conditions such as wound care.

Need For A Quick Fix

  UMMC’s ED patient volume exceeded 110,000 visits in 2011, with approximately 75 percent being adults. With this demand for care came an increase in the number of patients experiencing wound care/skin infection complaints (7,095 patients). Many of these same patients were found to be returning to the ED for multiple visits related to the same needs, resulting in care that proved expensive for them as well as the facility. Also home to Mississippi’s only Level I trauma center, children’s hospital, and transplant center, UMMC is the largest diagnostic, treatment and referral care system located in the state (722 beds). Inpatient stays total approximately 29,000 annually, with more than 209,000 outpatient and emergency visits each year. The adult ED includes a 35-bed unit with areas devoted to trauma, general medicine, orthopedics, and non-urgent care area. The Rapid Track is staffed 16 hours per day by family nurse practitioners who are experienced in urgent care management and operates with the following goals at the forefront:     • providing timely access to a WCS;     • providing education on wound care management and procedures;     • providing continuity of care; and     • decreasing ED visits for wound care management.   Patients arriving to the ED with a skin infection or wound care issue are triaged by a nurse practitioner (NP) for appropriateness of care and a consult with a WCS is performed if the NP is unable to treat the patient with a single ED visit. Consults allow for a baseline assessment and early intervention by a WCS if needed. In these instances the NP accompanies the wound physician during the patient’s evaluation and treatment. This collaboration has benefited the NP with training in procedures such as incision and drainage, debridement, nail removal, and application of various wound dressings. At the time of discharge from the ED all patients are given follow-up appointments with the specialist to foster continuity of care.

Results Seen

  Between May 2011 and August 2012, 76 wound care consults for unique patient encounters were provided in the Rapid Track. Many patients required additional clinic follow up by the WCS on an outpatient basis during this timeframe, which has fulfilled the goal of reducing census in the ED as well as improving continuity of care. Harriet L. Jones, MD, BSN, FAPWCA, associate professor of medicine and physician wound specialist at UMMC, has been very impressed with the success of the program thus far: “One of the first nurse practitioners who embraced the concept of what we were trying to do had previously been a wound care provider at a facility nearby. She was such an important contact and helped remind other Rapid Track providers that there was now somewhere to refer their patients for follow up. Patients also appreciated the fact that they had a more appropriate and user-friendly venue for subsequent care. This program continues to help offset the long wait times associated with wound patients. Additionally, we have found some patients have earlier, more appropriate intervention and fewer inappropriate treatments, such as prescriptions for systemic antibiotics, that may not really be indicated. Almost a year after this program started, I was seeing a patient new to me who had been referred from the ED for a follow up, and I’m very proud to say the continuity of care we provided may have prevented an unnecessary limb amputation.”

Future Focus

  With the success UMMC officials have seen with the Rapid Track program, the next step to improving wound care management at the facility is already underway. With a focus on expanding the reach of the Rapid Track beyond the hospital walls, a telemedicine program is on the horizon that is expected to deliver care by wound specialists across the state. Set to launch this October, the telewound service will allow local community hospitals, nursing homes, and clinics to request a WCS consult with UMMC physicians. Kristi A. Henderson is associate professor in the school of nursing and chief advanced practice officer at the UMMC. She can be reached at khenderson@umc.edu. Harriet L. Jones, MD, BSN, FAPWCA, associate professor of medicine and physician wound specialist at UMMC, contributed to this article.

References

1. Nawar EW, Niska RW, Xu J. National hospital ambulatory medical care survey: 2005. Adv Data. 2007;386:1-32. 2. CDC. Fast Stats ER Visits. 2012. Retrieved online at www.cdc.gov/nchs/fastats/ervisits.htm. 3. Pfaff J, Moore G. ED wound management:identifying and reducing risk. ED Legal Letter. 2005;16:97-108.