Wound Outcomes from a Single Practice at a Subacute Wound Care Unit and Two Hospital-Based, Outpatient Wound Clinics

Introduction The field of wound care continues to grow and mature with time. Randomized, controlled trials are replacing case reports, and clinicians are now focusing on outcomes data instead of relying only on experience when making clinical decisions. There have been several reports in the literature analyzing healing rates and overall outcomes from hospital-based wound clinics.[1] Some of these reports represent a single practitioner’s experience, whereas many are composites from numerous clinicians each participating in the wound center for a limited time each week. Attempts at aggregating multiple hospital-based wound clinic data via a corporate based, centralized database have also been reported.[2] As the healthcare system has changed over the past 5 to 10 years, there is a move towards earlier hospital discharge. As a result of staffing and economic issues, home health agencies have been forced to reduce visits and focus on training both patients and family members in wound care rather than provide wound care over extended periods of time. Caring for patients with medically complex wounds can therefore be problematic. Not all patients are able to be transported back and forth to the outpatient clinic following a hospital stay. Advocate Healthcare System, comprised of eight hospitals, is one of the nations top 10 not-for-profit healthcare delivery systems based in Oakbrook, Illinois. An outpatient wound program based in Advocate Christ Medical Center, a 662–bed level one trauma center, was developed in November 1998. Outcomes data were recorded from the clinic and compared to data derived from a community hospital-based wound program where the authors had previously practiced. After confirming similar outcomes to those achieved in the authors’ prior practice and having standards in place, attention was turned to the growing number of medically complex wound patients that were being referred to this tertiary care center. Many of these patients required hospital admission, surgical procedures, and medical stabilization. Length of stay, cost of care, and the orchestration of multiple specialists providing consultations were a few of the many obstacles that required solutions. A subacute wound care program was therefore established offsite with the objective of transitioning the wound care patient from the hospital to a home care environment. A centralized, system-based wound care council was created at Advocate Healthcare. The council is responsible for supply chain management, a wound product formulary, specialty support surfaces, and the development of standard policies and procedures. Current projects include conducting quarterly prevalence and incidence studies for nosocomial pressure ulcers. Long-term goals include driving quality throughout the system by establishing a wound-care “network,” which would link the hospital-based wound programs together electronically and allow for the development of subsequent subacute programs. There is a paucity of outcomes data from the subacute and long term care environment concerning healing rates and overall wound care outcomes. This paper describes the outcomes and data from two separate hospital programs and a 36-bed, dedicated, subacute care wound unit. These three programs were all organized and staffed by the same team of clinicians spanning five years of clinical experience applying the same standard policies and procedures. Data gathered from outpatient wound clinics should not be used to establish healing rates or benchmarks for the long-term, subacute care industry. Patients in these different settings have different levels of illness and comorbidities. Unfortunately, regulatory agencies and health departments have few documented and published outcomes in the literature to benchmark for creating quality standards. Also, based on severity of illness and demographics, subacute care programs have different outcomes from standard long -term care facilities. As society ages and more patients spend time in these types of facilities we need to develop treatment programs, algorithms and acceptable outcomes in order to help standardize care, improve economic efficiencies, improve quality of care, and reduce medical error and complication rates for patients. In addition the explosion of assisted living centers and elder-community settings will provide additional wound care delivery needs and reliable outcomes measures. Purpose This paper attempts to address the importance of identifying not only the patient population but the site of care when analyzing outcomes. The same clinical team sequentially provided care at a community hospital for two years at a tertiary care hospital for one year, and finally at a subacute care wound unit for three years, which provided the basis for this study. Since the clinical team and wound care protocols are constant, the outcomes should be a more accurate reflection of the patient population and point of service. Methods Hospital-Based Wound Clinics. Data was prospectively captured on all patients served during the last two years of clinic operations from a 150-bed community hospital where the authors were running an outpatient wound program (1997–1998). The program was mature (3 years old) at the start of the data analysis and well-established protocols were in use. The authors performed all patient examinations and entered the data weekly into a statistical database (SPSS® software. There were no inclusion/exclusion criteria; all treated patients were entered. Initial visit information included wound etiology, wound measurements, vascular assessment, lab testing, and imaging when indicated. Wound measurements were performed by ruler measurement and photographic grid analysis for wound area calculations. The clinical diagnostic and treatment protocol followed the previously published Least Common Denominator Model (LCD model©) and the Comprehensive Wound Assessment and Treatment System (CWATS©) used previously to standardize wound assessment and guide treatment.[3] Treatments included various interventions (e.g., electrical stimulation, ultrasound, negative pressure therapy, compression therapy, surgical debridements, revascularization, flap and skin graft coverage) applied in accordance with moist healing principles determined by the authors to be most clinically appropriate. The wound care outcomes thus derived are “real world” clinically achievable results not limited by randomization and conforming exclusion criteria. Patients who were seen only for consult or for vascular assessment where no wound was identified were not included in the study. The authors moved the program to the tertiary care, academic center in November 1998. The clinical team including nursing, physical therapy, outcomes software program, clinical treatment protocols, and the authors remained the same. New surgical and medical specialists were recruited to join the clinical program. Data were captured prospectively for the first year of the program in an identical fashion to that described previously. Due to the rapid growth of the inpatient service and the subacute unit, data collection became logistically and economically impossible. Attention was turned to the subacute unit at this point. Subacute Unit. A 36-bed dedicated subacute wound unit was created in 1999 within a 275-bed long-term care and rehabilitation facility. Patients are seen by nursing and physical therapy daily and by the authors at least weekly. The same treatment protocols and data capture techniques were utilized. Again, no patient was excluded from the database. Data was prospectively collected over three years ending July 2003. The clinical team at the subacute unit was trained by the authors and work closely with the hospital-based team. Results The results from all three facilities were analyzed together. In total, 1,406 individual wounds were available for analysis. The community hospital program was much smaller in volume and therefore the two-year totals were very similar to one year’s experience at the tertiary facility (375 wounds vs. 351, respectively). A total of 680 wounds were reviewed from the three-year experience at the subacute program. Demographics from the three programs are noted in (Table 1). There were no differences in healing rates or Kaplan-Meier median time to healing resulting from differences in race and gender (Table 2). There was a highly statistical difference between the units, however, when reviewing Kaplan-Meier median times to healing based on the site of care (Table 3). The two hospital-based outpatient clinics were similar, but patients in both hospital settings had statistically faster median times to healing and healing percentage (p50% volume reduction), was calculated for the subacute unit.[4] An additional 30 percent of wounds were found to be in this category with a mean of 17 weeks and a median of 11 weeks healing times as estimated by Kaplan-Meier survival analyses. Using this parameter along with healing, a total of 53 percent of wounds achieved healing or marked improvement. A p value of 0.0251 was achieved using Log Rank analysis when comparing the three units on the basis of patient age, patients over 70 years of age, the largest segment of the treated population, experienced delayed healing more in the subacute setting than in either hospital setting (Table 4.) Although the subacute unit achieved lower healing percentages across all age groups, patients under 50 years of age experienced a shorter median healing time in subacute care. Across all settings, the lowest percentages of wounds of arterial etiology healed (Table 5). The lowest percentages of all wound etiologies healed in the subacute setting (p=0.0137), while there were no statistically significant differences between the two hospital programs in the distribution of percents of the various wound etiologies healed. This result is consistent with all of the previously described analyses. Discussion Outcomes research continues to play an important role as evidence-based medicine gains recognition. Recently, the wound care community has focused more attention on healing outcomes. Outpatient, hospital-based wound clinics historically see patients with leg ulcers and in particular venous ulcers as the predominant wound type. The scope and variety of cases referred to the clinic will depend to a large degree on the level of care provided at the sponsoring hospital. With appropriate vascular testing equipment, an accurate diagnosis of a leg ulcer can be made with a single visit.[5] Even for venous leg ulcers, the most common outpatient wound type, healing rates at 12 weeks ranged from only 56 percent to 69 percent in one study based on the adequacy of the underlying arterial flow.[6] The initial rate of healing has been suggested to predict overall venous ulcer healing.[7,8,9] Specifically, the percentage of area reduction noted from baseline to Week 29 to 410 of therapy appears to be predictive of overall healing. Other ratios derived from baseline and four weeks of therapy are being viewed as possible surrogate endpoints to predict healing.[11] Other investigators are applying the same analysis including four week area reduction, surrogate endpoints, and clinical predictors for healing to the population of diabetic foot ulcer patients.[12,13,14] The authors’ results in treating 726 wounds at two different hospital-based clinics demonstrate a 73 percent overall healing rate. The authors were unable to find any statistically significant differences among the various wound etiologies at either hospital-based program. The wound clinic model is not isolated to the United States. There is now a growing base of wound care centers around the world.[15,16,17] Our data also describe that with a consistent clinical approach, consistent outcomes are achievable at two very different hospital settings. As the population ages and clinicians are faced with more medically complex, older patients, the delivery model for wound care will need to evolve. The hospital-based wound care clinic has and will continue to be the focal point of what should be a more integrative wound care “network.” The wound program at Advocate Christ Medical Center is comprehensive, treating any and all wound types. In 2003, a total of 7,000 patient visits were performed by the physician team, 3,500 patient visits by the hospital-based physical therapy team, and an additional 4,000 patient visits by the subacute based physical therapy team. The authors’ hospital-based program provided 2,500 outpatient visits in 2003. During the same time frame, 3,000 inpatient visits and 1,600 subacute patient visits were carried out. One hundred and sixty patients were admitted directly for wound related issues in 2003. This resulted in $3,525,108 in gross hospital charges and $1,888,261 direct revenue. Direct patient care costs were $651,447, which resulted in a contribution margin of 1.1 million dollars for the hospital to apply to indirect overhead. The overall gain/loss including allocated indirect costs was a positive million dollars to the bottom line. The only way that these economic benefits could be realized while maintaining quality of care was through the development of a subacute wound unit that is clinically capable of providing a high level of care for medically complex patients. Length of stay can be managed effectively without compromising care. Similar integrated outpatient and inpatient services have been created in Europe.[18,19] There is a selection bias that needs to be addressed when evaluating a subacute wound unit. Only those patients from the hospital-based clinic that require inpatient care and surgical procedures and are not candidates for home health care are eventually enrolled. Therefore, the “healthy” wound patients would be more likely to remain only in the hospital-based clinic population. In addition, there is a time limit for therapy to occur. The goal of such a program is to transition the patient along the continuum of care in a time and cost-effective manner. Kaplan-Meier median time to healing in the outpatient hospital-based clinic was 59.5 days compared to 77 days in the subacute unit. The average age of the patient is older and the number of co-morbid illnesses is greater in the subacute patient population. There is a paucity of data concerning healing rates in these care settings which, are likely to house more challenged patients within the continuum of care, as are long-term care environments. The majority of data for the long-term care community reflects pressure ulcer healing. In one report, a 64.7 percent healing rate was noted at six months for stage 2 wounds, 39.9 percent for stage 3, and 34.1 percent for stage 4 ulcers.[20] A study conducted through the VA system found 72 percent healing for stage 2 wounds at six months, 45.2 percent for stage 3, and 30.6 percent for stage 4 ulcers.[21] Through awareness of the delayed or less likely healing outcomes in these different settings, professionals can better prepare themselves and their facility management to address their patients’ challenges. In addition to overall healing, there is an additional surrogate outcome to total healing that merits discussion. In an abstract detailing the authors’ initial results from the subacute unit, the authors’ noted a 30 percent healing and 36 percent marked improvement rate for 471 wounds. Currently, the authors have analyzed 680 wounds and have found similar results. The concept of marked improvement (>50% reduction) is important for both patients and payors. The authors’ goal in the subacute program is to move the patient along the care continuum. By achieving a significant volume reduction, many of these wounds became manageable in the home setting either with home health or family support. Payors often desire a predictable outcome prior to approving care at a site other than the home environment. If quantifiable outcomes and costs could be achieved in a finite time period, the cost effectiveness of care could be determined. This concept also works when considering palliative care for wound patients. Not all patients are capable of healing, yet this population could benefit from improving wound pain or patient quality of the life, reducing wound size, and controlling infection so that the patient can return from an institutional setting to the home environment.[22,23] Clinicians frequently have a difficult time in agreeing to what is meant by a completely healed wound, further complicating understanding of the literature.[24] In this paper, the authors have identified some baseline healing and improvement rates for a dedicated subacute wound unit. The previously mentioned healing trajectories for venous and diabetic wounds were derived from acute care hospital-based programs. The authors wanted to see if there was any correlation with the subacute wound population and have generated four week volume and area reduction curves for those patients that ultimately healed or achieved marked improvement and for the total cohort. (Figures 1 and 2.) Obvious differences are noted. In wounds that heal or markedly improve, there is a small initial increase in volume followed by three consistent weeks of volume reduction. The initial increase is secondary to the fact that almost all wounds are initially debrided as part of the treatment protocol. By Week three, a prediction could be made as to whether a wound was likely to heal or markedly improve. The same pattern was noted for the area reduction curves with the exception of the first week. Since debridement impacts depth more than length and width, it is not surprising that the area is essentially unchanged after the first week. These results are preliminary and further work is needed to confirm them. It appears that the results of four-week healing trajectories reported by others may also have implications for the subacute setting. Thus, in addition to allowing clinicians to track efficacy and cost effectiveness of their outcomes, measuring wound healing outcomes appears to have predictive value for wounds of a variety of outcomes cared for in a variety of settings, including the subacute care environment.