1. Dermatology Wound Clinic Jessica Scanlon, MD October 9, 2014

2. 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)

3. What We Do Management of chronic wounds – Wounds lasting longer than 6 weeks – Frequent wounds – Pts with a history of chronic wounds – Complex wounds

4. Conditions We Treat The 3 big chronic wounds: – Venous leg ulcers – Diabetic foot ulcers – Arterial ulcers Complex dermatologic conditions – Pyoderma gangrenosum – Morphea – Radiation dermatitis – Vasculitis – Infection – NLD – Calciphylaxis – Tumors – Etc…

5. What We See

11. Chronic Wounds Wound management is complex Requires frequent wound and dressing reassessment

12. How Do We Operate Team approach – Everyone has an important role in wound care Important team players – 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

13. Managing Comorbidities A chronic wound is a systemic disease – affected by a host of other factors – 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…

14. 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

15. Choosing Appropriate Wound Dressings Assessment of the wound/milieu – Moisture balance – Inflammation – Necrotic debris, crusting – Bacterial bioburden (odor, drainage) – Quality of the skin (ACD, xerosis, stasis, etc) Comorbid factors – Ease of dressing changes – Pain – Is the person changing the dressings making things worse? – Dressing availability, cost

16. Tools Dressings Debridement – Sharp debridement, collagenase Compression Topical agents – Regranex Bio-Engineered Grafts – OASIS, Apligraf, Dermagraft, EpiFix Antiseptic measures

17. Maintaining the Moisture Balance Tegaderm (film) Duoderm (hydrocolloid) Aquacel (hydrofiber) Allevyn foam cavity dressing (foam)

18. Antiseptic Dressings

19. Compression

20. 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

21. Wound Clinic Much of the work is done outside of clinic, by support staff – 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

22. Care Coordination 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

23. Logistics Scheduling – Urgent issues – All others go through our scheduler Days – Thursdays AM/PM, Vince monthly – Bill Wednesdays Location – 221 Longwood Inpatient consult service