The Referral Resurrection: Revive Your Clinic's Use of Physician Contacts

Not Everyone Knows What You Do

  One day after work, this author was standing in the checkout line at a local business with two of the nurses from her clinic. One of the nurses recognized a former coworker who was also waiting in line. During their exchange of greetings, the coworker asked where the author’s nurse was currently working. The nurse replied, “at the River Oaks Wound Center”. The former coworker appeared very confused asking her again, “where?” Again, the nurse answered in a truly southern drawn-out fashion, “at the wound center.” Still unclear, the coworker questioned “the womb center, what is that?” The author’s group found the exchange funny at the time, however they did not realize how fortuitous it had truly been.

Understand What Your Clinic Is Good At

  Like most wound care centers across the country, the majority of the facility’s patients are referred for evaluation and management of lower extremity wounds. However, since opening the Wound Care and Hyperbaric Medicine Center at River Oaks, Flowood, Mississippi three years ago, the author’s clinic has treated just over 100 abdominal wounds. These have included patients who have undergone Cesarean sections, hysterectomies, abdominoplasties, colon resections and implantation of transcutaneous pain control devises in which creation of an abdominal pocket is required. The expansion of the clinic’s practice to include patients with these and other abdominal wounds started as follow up visits subsequent to formal inpatient consultations. Seeing patients initially as an inpatient not only improves the transition of the patient's care to the outpatient setting, but is also improves the in-house visibility as the wound specialist, encourages consultations, and further enhances peer-to-peer relationships. Referrals from other surgical specialties are also being made earlier in the patient's postoperative period. Additionally, other patients with these types of non-healing wounds have self referred and/or requested a referral from their primary physician/surgeon.

Signs and Symptoms

  It is common that once a patient is referred, their history usually includes being approximately two weeks post-procedure with some combination of—increased edema around the suture/incision line, worsening pain, impressive erythema, periwound induration, and irregular episodic drainage. Many times patients report that the incision line leaks even with what appears to be well re-approximated skin edges. Some drainage early in the postoperative period is expected and normal. However, the kind that heralds a non-healing wound is significantly different as it may—have a mild odor, appear slightly cloudy with a clear serous or serosanguinous discoloration, be more viscous than normal serous leakage, and require that the patient change an absorbant dressing several times a day.

Becoming The Expert

  When this type of drainage is present, particularly with the other signs and symptoms mentioned, the normal phases of healing are being interrupted and the wound is likely to become secondarily infected or stalled in the inflammatory phase of healing. Because the treatment of an abscess has always been, and continues to be drainage—patients are already ahead of the game if they have had spontaneous drainage. However, the exact site of leakage often is unrecognized and inadvertently overlooked by the patient and primary physician therefore delaying this important process. A maneuver that will often identify the site of leakage is to gently stroke the incision line with the blunted end of a surgical instrument (forceps, currette, or small bone probe). In patients who have had their staples removed or whose wounds were closed with surgical skin glue, this mechanical challenge is often all that is needed to allow the skin edges to literally unzip (become separated) with minimally invasive manipulation. Surprisingly, most patients tolerate this with little or no local anesthetic.   Further exploration and assessment of the now-exposed subcutaneous space can now proceed but may require topical local anesthetic. This is usually more than sufficient for the patients’ comfort especially if they have an average level of pain tolerance. Not infrequently hematomas, excessive stacked subcutaneous suture knots; collections of polymicrobial infection and pockets of other fluids are identified as what is believed to be the reason/culprit for these wounds to not heal. The patient's wound can be assessed and treated without having the patient undergo another formal intraoperative procedure since when these wounds are considered ‘dirty’ and as long as there are no other compelling reasons not to do so.   Subsequent irrigation with or without local debridement can be done in the clinic setting. Many centers are equipped with more advanced devices beyond the normal scalpels and curettes, which allow for nearly painless debridements. Examples of devices include pulsed lavage with suction, ultrasonic debridement devices, and low frequency, non-contact, non-thermal ultrasound, which often eliminates the need for topical anesthesia. Benefits of clinic based abdominal wound management include but are not limited to:     1) The patient foregoes readmission to the hospital.     2) Unnecessary use of healthcare resources and expense is spared for all involved.     3) The problem is dealt with immediately - without waiting for an O.R. posting.     4) The patient's time is best utilized.     5) Other hospitalized patients and their caregivers are not exposed to other potential pathogens.   This also provides a great opportunity to obtain appropriate cultures prior to the addition (often knee jerk response) of emperic oral or intravenous systemic antibiotics. If patients are afebrile, normotensive, hemodynamically stable, and don't appear systemically ill, then systemic antibiotics may not even be needed.

Understanding Why Referrals Work

  In preparation for writing this article the author contacted two referring physicians to her practice and asked them two questions     1) What is it about our clinic that makes you comfortable entrusting the care of your patients to us?     2) What would or has made you uncomfortable in doing the same?   Their responses were very informative and reinforced the belief that this population of patients with non-healing wounds should not be overlooked and should be considered as a referral base to specialty wound care centers. In response to the first question, each of the colleagues recognized that the clinic provides a very specialized service and has the infrastructure in place to efficiently deliver this level of care. Unlike the referring physicians' offices everything about the author’s clinic—from the facility, materials and personnel, is geared to take care of wounds. The clinic offers their patients the state-of-the-art products developed specifically for wound healing. A variety of products on site are readily available, which enable the clinic to develop a tailored plan of care specific to meet the patient's needs. These include negative pressure wound therapy dressings, antimicrobial dressings, specialized assessment tools such as TCPO2, compression wraps, and specialty elastic bandages. This offers peace of mind to the referring physician and patient and often allows the patient a less restrictive wound-dressing regimen and affords them the opportunity to resume working or just return to a more normal routine. The clinic’s knowledgeable staff provides patients and their caregivers hands-on, individual instruction on caring for the patient's wound at home. The staff also assists patients in choosing outside resources, which can be confusing and add to their stress levels.

Building Relationships

  The old saying that everything one needs to know was learned in kindergarten is really true. It is no surprise that, the most important factor underpinning both of the questions addressed by the author’s colleagues was the peer-to-peer relationship. In addition to the facts that this author's clinical background is Infectious Diseases and she is able to practice wound care full-time, the most important reason for referral seems to be the longstanding relationships. This translates to the other physicians and staff who work in the clinic, and can be true for all staff of every clinic. Whether one is able to practice full-time in wound care or is part of a larger team, the relationships among colleagues drives referrals.   A key aspect for repeat referral seems to be the referring physician’s ability to assure their patients that they will be seen by ones clinic sooner than later. The opposite of this is also true. If any member of the physician’s office gives the impression that your clinic can’t serve their needs, negative results can occur and referrals might stop. Timely communications of the clinic’s assessment and plan, whether by phone or email, along with updates of any unusual development during the time the patient is under care, is beneficial for future referrals.   As a wound care physician, this author has found the challenges of treating patients with abdominal wounds extremely rewarding. Once there has been a complete assessment with development of an appropriate plan and the patient becomes engaged in their care, these wounds usually heal extremely fast—barring any unexpected development. This can be very satisfying to everyone involved. However, the most rewarding part of all of this, no matter what kind of wound one is treating, is having a patient or their physician share how appreciative they are that they were helped through such a trying time physically, emotionally, and mentally. Harriet Jones, MD, BSN is the Medical Director and fulltime physician at the Wound Care and Hyperbaric Medicine Center at River Oaks in Flowood, Mississippi. Her email address is harriet.jones@roh.hma-corp.com.