Development of a Wound Care and Hyperbaric Medicine Center
Excerpted from Chapter 4: Development of a Wound Care and Hyperbaric Medicine Center in Hyperbaric Facility Safety:
A Practical Guide by Rudy C. Pruneda. It is reprinted with permission of the publisher, Best Publishing Company.
The need for a center that specializes in healing diabetic, venous stasis, and other chronic wounds is self-evident. In addition, many physicians and podiatrists do not possess all the tools or protocols that can successfully heal recalcitrant ulcers. The challenge of chronic ulcers is complex and involves multifactorial problems. A complete assessment by physicians and nurses, laboratories, and other diagnostic tests is required to confirm clinical judgment, and the treatment plan may call for surgical intervention, nutritional assistance, off-loading of affected limbs, compression therapy, antibiotics, etc. The center should contain the appropriate diagnostic and therapeutic equipment to perform the majority of wound care inside the premises, thus allowing patients to confine their visits to one area.
Role of Wound Care Specialists
This type of treatment is best undertaken in a center that incorporates various physician specialties (orthopedic, plastic, and vascular surgeons; infectious disease specialists; podiatrists; endocrinologists) and nurses and technicians trained in wound care and hyperbaric oxygen. Treatment protocols are designed with the understanding that a chronic wound should be converted to an acute wound via a surgical debridement, when appropriate. If infected, the wound should also be treated with antibiotics until no visible signs of infection are present.
The wound environment is kept moist to facilitate fibroblast formation; therefore wound dressings are applied that allow the proper environment to exist. Edema is removed from wounds with compression wraps, stockings, and pumps. Protocols are agreed upon by the wound care team, and forms are designed to record visit activities, wound measurements, and any other diagnostic or therapeutic activities. In certain cases, hyperbaric oxygen therapy is recommended.
Role of Hyperbaric Oxygen in Wound Healing and Infection Control
Studies by Pai and Hunt6 revealed oxygen plays a critical role in wound healing. Their studies revealed that increasing the oxygen levels improved the healing of wounds. Knighton7 showed that oxygen acts as an antibiotic, which allows white blood cells to form oxygen radicals that destroy bacterial cell walls. Other researchers have been able to show that oxygen and certain antibiotics act synergistically to destroy bacteria.8,9 Sheffield10 demonstrated that wounds heal better when hyperbaric oxygen is used.
Identifying Team Members
Most communities will have certain physicians and podiatrists who are known as the “wound care experts,” and their fellow doctors will usually refer difficult-to-heal wounds to these individuals. These doctors will usually welcome the opportunity to join a center that is organized to support his/ her efforts. Reimbursement for supplies is usually negligible in a physician’s office, plus the doctor has to pay staff to support his medical and billing functions. The wound center can make staff and supplies available to the doctor’s patients. As an outpatient center of the hospital, the supplies are covered, and the staff belongs to the contractor of the wound care service or the hospital; therefore the doctor is spared these expenses. In addition, the wound care center provides forms that allow the doctor to keep track of his professional activities and billing.
It is important to establish a multidisciplinary team of doctors, which can support wound healing activities. Initially, infected wounds contain necrotic tissue or wound fluids that inhibit healing and must be removed.13 Availability of a general surgeon who understands the importance of debridement to fresh, bleeding tissue or cancellous bone is optimal. In other cases, revascularization may be needed to support blood flow to the lower leg. A vascular surgeon is ideal in these instances. Other times, a large shallow wound may be better covered with a muscle flap or skin graft, thus a plastic surgeon is needed.
In diabetics, it is vital that blood sugars are kept under control to prevent the harmful effects of compromised white blood cells14 and formation of deposits on blood vessels that constrict blood flow.15 Internal medicine, endocrinology, and diabetic education nursing specialties can help develop treatment plans that include medication and diet modification. Diabetics also suffer from infections more severely than normal patients.16 Many times, a simple cut may lead to gangrene or osteomyelitis. Infectious disease specialists can often help guide the administration of IV antibiotics and subsequent oral antibiotics.
Nurses with specialty training in wound care are often difficult to recruit. Enterostomal nurses have the background and experience in wounds; unfortunately these nurses are usually only found working in large or teaching university hospitals. As a general rule, inexperienced RNs and LVNs can be trained at hyperbaric medicine courses recognized by the Undersea and Hyperbaric Medical Society (UHMS). More information can be obtained online at www.UHMS.org. Certain basic wound care courses provide excellent information on the physiology of wounds, treatment protocols, and current innovations in wound supplies.
Trained hyperbaric technicians are also very difficult to recruit, so individuals with EMT backgrounds or previous military hyperbaric training can be hired and trained in- house. These individuals help with wound care, monitor the hyperbaric treatments, and perform maintenance on the hyperbaric chambers.
Location of Wound Center
Ideally, the wound center should be located on the hospital premises. This allows better coordination of patient transportation, diagnostic testing, dietician support, and services such as physical therapy, surgery, and laboratory support. Access to the hospital parking lot is important, especially with wheelchair access.
Figure 1. Wound Center with good patient flow
Many times hospital space is at a premium or occupied with other services, and the wound center must be located in a professional building adjacent to the hospital. In these cases, transportation becomes an important consideration. Covered hallways to the hospital should be considered to help minimize exposure of patients to inclement weather. Wheelchair and stretcher access, with doors having a minimum space clearance, must be considered when developing the program.
Flow of Patients in the Center
Consideration should be given to establishing a traffic flow that does not result in bottlenecks throughout the day. There will usually be three types of patients in the center: new patients for evaluation, patients for wound care only, and patients for wound care and hyperbaric oxygen therapy. Space should be established so that patient flow is in one direction — from entrance to exit, thus minimizing patients crowding hallways and/or waiting for evaluation or wound care procedures. Figure 1 gives an example of a wound center that allows good patient flow.
Each state may have requirements that must be followed when building a wound care/hyperbaric medicine center. For example, in Texas certain requirements are outlined for wound centers that have hyperbaric facilities.17 The following are considered the minimum requirements for a hyperbaric suite:
Patient waiting area: The area should be out of traffic flow, under staff control, and contain enough seating capacity for patients and their relatives throughout the day. When the waiting area is for both inpatients and outpatients at the same time, separate areas shall be provided with privacy between both areas. Patient waiting areas are not required for two or fewer individual hyperbaric chambers.
Control desk and reception area: A control desk and reception area shall be provided to greet patients, fill out registration information, and serve as traffic control center throughout the day.
Holding area: This area should accommodate inpatients on stretchers or beds and be out of the traffic flow. This area may be omitted for two or fewer hyperbaric chamber facilities.
Patient toilet rooms: Toilet rooms shall be provided with hand-washing fixtures, which have hands- free operable controls with direct access from the hyperbaric suite.
Patient dressing rooms: Dressing rooms for outpatients should include a seat or bench, mirror, and provisions for hanging patients’ clothing and for securing valuables. At least one patient dressing room should accommodate wheelchair patients.
Staff facilities: Toilets with hand-washing fixtures with hands-free operable controls may be outside the suite but convenient for staff use.
Consultation room: An appropriate room for private consultations with wound care physicians shall be provided for outpatients.
Storage space: A clean storage space shall be provided for clean supplies and linens. Hand- washing fixtures shall be provided with hands- free operable controls. When a separate storage room is provided, it may be shared with another department.
Soiled holding room: A soiled holding room shall be provided with waste receptacles and soiled linen receptacles.
Hand washing: A lavatory equipped for hand washing with hands-free operable controls shall be located in the room where the hyperbaric chambers are located.
Housekeeping room: The housekeeping room shall contain a floor receptor or service sink, storage space for housekeeping supplies and equipment, and be nearby.
The hyperbaric area should be large enough to allow two to four monoplace chambers or one multiplace chamber, plus room for stretchers and a console area where a technician or nurse can monitor the treatments and communicate with patients and/or staff inside the chamber. Space between monoplace chambers is as follows: chamber and sidewall, five feet; between chambers, six feet; and between the chamber headboard and wall, three feet. A minimum passage space of four feet shall exist at the head of the chamber. Typically, a monoplace operation may require between 2,000-2,500 sq. ft. for all operations, while a multiplace chamber operation may require 3,000-4,000 sq. ft.
Timetable for Establishing a Wound Center
In general, the timetable for opening a wound center with monoplace chambers may vary from 90 days to 180 days, depending on approval by state agencies, architect plans, administration approvals, etc. A multiplace chamber installation may take up to one year before patients can be treated. The following steps must be accomplished to help expedite final construction and patient treatments:
- Architectural drawings completed
- Approval by the state agency to begin construction
- Approval of a contractor to begin construction
- Completion of construction and approval by local fire marshals for occupancy
- Final inspection by state agency to begin patient treatments
Ordering chamber(s): Normally chamber manufacturers need six to eight weeks for construction once the order is placed. Schedule chambers to arrive approximately the same time as final state inspection. A multiplace chamber may require six months to a year for construction. Many times, construction is done around a multiplace chamber, so coordination of this facility is much more involved.
Connect chambers and perform safety checks to ensure chambers are operational. Conduct training of medical personnel to ensure safe chamber operation.
- Wound care chairs
- Wound care lamps
- Transcutaneous oxygen monitors
- Surgical supplies for debridement procedures
- Digital camera for wound photos
- Computer to record wound care activities and schedule patients
- Curlex rolls
- Specialty dressing
- Compression wraps
Once the decision is made to run a wound program, education of the hospital staff should begin. Nurses on the floors may provide good referrals on wound care patients. Educational efforts may be in the form of literature on wound care, newsletters, videos, or scheduling wound care specialists to give talks on the subject. If continuing medical education (CME) units are included, physicians and nurses from outside the hospital will be encouraged to attend. Home health agencies are a good target group, since they care for the majority of patients outside the hospital.
The general public should also be educated and made aware of this service in the community. The most common forms of advertisement include television, radio, and print ads. These ads may be aimed at certain populations, i.e., diabetics or patients with venous stasis disease. Scheduling of ads should be aimed at starting immediately before the wound center is ready to treat patients and should run until the wound center is well established.
Establishment of a successful wound care/hyperbaric medicine is based on several factors: (1) a patient population that needs the service; (2) a team of physicians, nurses, and technicians committed to the cause of wound healing; and (3) a hospital that is willing to commit the resources necessary to provide the service to the community and surrounding areas. Requirements for construction of the wound center/hyperbaric medicine facility will vary depending on local, county, state, and NFPA 99 requirements. Marketing the program will require identifying the medical community to educate as well as the public, which ultimately benefits from the service in community. The wound center can certainly impact the quality of life for patients who have previously found these wounds debilitating and costly to the health care system.
- Cowie CC, Eberhardt MS. Diabetes: 1996 Vital Statistics. Alexandria, VA: American Diabetes Association; 1996.
- Palumbo PJ, Melton LJ. Peripheral vascular disease and diabetes. In: Diabetes in America: Diabetes Data Compiled in 1984. Washington, DC: US Government Printing Office; 1985; HIH 85-1468.
- Cianci P, et al. Salvage of the problem wound and potential amputation with wound care and adjunctive hyperbaric oxygen therapy: an economic analysis. J Hyperbaric Med. 1988; 3:127-41.
- Jordon R. Etiology and treatment of venous leg ulcers. The Clinicians’ Notebook. 1998; 2(2):5.
- US Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Government Printing Office; 1991; DHHS: 95-50213; 73-177.
- Pai M, Hunt TK. Effect of varying oxygen tensions on healing open wounds. Surg Gynecol. 1972; 135:756-8.
- Knighton DR, et al. Oxygen tension regulates the expression of angiogenesis factor by macrophages. Science. 1983; 221:1283-5.
- Mader JT, et al. Potentiation of tobramycin by hyperbaric oxygen in experimental Pseudomonas aeruginosa osteomyelitis. New York: Presented at the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy; 1987.
- Mader JT, et al. A mechanism for the amelioration by hyperbric oxygen of experimental staphylococcal osteomyelitis in rabbits. J Infect Dis. 1980; 142:915-22.
- Sheffield PJ. Tissue oxygen measurements. In: Davis JC, Hunt TK, eds. Problem Wounds: The Role of Oxygen. New York: Elsevier; 1988.
- Rith-Najarian L, et al. Foot care in minorities: preventing amputations in high-risk populations. In: Levin ME, O’Neal LW, Bowker JH, eds. The Diabetic Foot. St. Louis, MO: Mosby Year Book; 1993.
- Division of Diabetes Translation. Diabetes Surveillance: 1980-87. Atlanta, GA: Centers for Disease Control; 1990.
- Wysocki AB, Grinnel F. Fibronectin profiles in normal and chronic wound fluid. Lab Invest. 1990; 63:825-31.
- Mader JT, et al. A mechanism for the amelioration by hyperbaric oxygen of experimetal staphylococcal osteomyelitis in rabbits. J Infect Dis. 1980; 142:915-22.
- Parving HH, et al. The effect of metabolic regulation on microvascular permeabilitiy to small and large molecules in short-term juvenile diabetes. Diabetologia. 1976; 12:161-9.
- Joseph WS, et al. The pathogenesis of diabetic foot infection immunopathy, angiopathy, and neuropathy. J. Foot Surg. 1987; 26:S7-S11.
- Texas Dept of Health and Human Resources. Physical plant requirements for a hyperbaric center. 1988.
- NFPA 99. Standard for Health Care Facilities. 1999 ed. Quincy, MA; National Fire Protection Association, 1999.