A case-study of the experiences of junior medical officers in the emergency departments of a metropolitan hospital and rural hospital.

OBJECTIVE: Increased exposure to post-graduate rural medical training is associated with increased likelihood of future rural practice. Training rotations in rural emergency departments provide a possible avenue for such exposure, but have been under-investigated. This study aimed to compare junior medical officers' emergency department experiences in a metropolitan and a rural hospital to inform rural health workforce initiatives. DESIGN: Mixed-method case-study design. SETTING: Two 10-week periods in the respective emergency departments. PARTICIPANTS: Four junior medical officers at the rural site and 22 junior medical officers at the metropolitan hospital. MAIN OUTCOME MEASURES: Caseloads extracted from electronic medical records and training experience. RESULTS: Data were collected over 142 days. The average number of patients seen per day, per junior medical officer, was significantly higher at the rural hospital emergency department (7.2 patients per day) in comparison with the metropolitan hospital (4.3 patients per day). Junior medical officers at the rural hospital saw relatively more lower acuity patients. The seven junior medical officers who were interviewed provided consistently positive responses regarding their training experiences in both locations. This was particularly evident in the rural hospital and was attributed to one-on-one supervision. CONCLUSIONS: Most junior medical officers agreed that their expectations for support and learning opportunities were met and/or exceeded. However, junior medical officers reported feeling more supported at the rural hospital due to direct contact and communication with senior medical officers. Placement in a smaller hospital emergency department did not disadvantage the junior medical officers' training in this case-study and provided a positive rural training experience. These findings support workforce policies which encourage rural hospital emergency department training.

A predictive model for pressure ulcer outcome: the Wound Healing Index.

PURPOSE: The purpose of this learning activity is to provide information regarding the creation of a risk-stratification system to predict the likelihood of the healing of body and heel pressure ulcers (PrUs). TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Explain the need for a PrU risk stratification tool.2. Describe the purpose and methodology of the study.3. Delineate the results of the study and development of the Wound Healing Index. OBJECTIVE: : To create a validated system to predict the healing likelihood of patients with body and heel pressure ulcers (PrUs), incorporating only patient- and wound-specific variables. DESIGN: The US Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, and so on). Significant variables were identified with bivariate analyses. Multivariable logistic regression models were created based on significant factors (P < .05) and tested on a 10% randomly selected hold-out sample. SETTING: Fifty-six wound clinics in 24 states PATIENTS: : A total of 7973 body PrUs and 2350 heel PrUs were eligible for analysis. INTERVENTION: Not applicable MAIN OUTCOME MEASURE: : Healed PrU MAIN RESULTS:: Because of missing data elements, the logistic regression development model included 6640 body PrUs, of which 4300 healed (64.8%), and the 10% validation sample included 709 PrUs, of which 477 healed (67.3%). For heel PrUs, the logistic regression development model included 1909 heel PrUs, of which 1240 healed (65.0%), and the 10% validation sample included 203 PrUs, of which 133 healed (65.5%). Variables significantly predicting healing were PrU size, PrU age, number of concurrent wounds of any etiology, PrU Stage III or IV, evidence of bioburden/infection, patient age, being nonambulatory, having renal transplant, paralysis, malnutrition, and/or patient hospitalization for any reason. CONCLUSIONS: Body and heel PrU Wound Healing Indices are comprehensive, user-friendly, and validated predictive models for likelihood of body and heel PrU healing. They can risk-stratify patients in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require advanced therapeutics to achieve healing.

When a LIC came to town: the impact of longitudinal integrated clerkships on a rural community of healthcare practice.

INTRODUCTION: Two small rural towns in Australia, where medical practitioners provide primary care to the population, including emergency, anaesthetic and obstetric services, were early adopters of an innovative year-long integrated clerkship (clinical placement) designed to foster medical student skill attainment and a commitment to underserved rural communities. Primary care vocational trainees had previously trained in the region. Engaging with the university to participate in the clerkship initiative for undergraduate medical education offered the local healthcare service an opportunity to really integrate education with service. This study sought perspectives from a multidisciplinary group of stakeholders on the impact of the longitudinal integrated clerkship (LIC) on the healthcare community. METHOD: Three analysts independently analysed the transcripts arising from semi-structured interviews with a range of health care clinicians and managers (N=23). Themes were identified using inductive content analysis methodology. RESULTS: Four major themes emerged from the perspectives of a multi-professional group of participants from both towns: transforming a community of practice, realising the potential of the health service, investment in rural return, and sustainability. CONCLUSIONS: There was significant clinical exposure, skill and teaching capacity in these previously unrecognised rural placements but realising the potential of the health service needs careful management to sustain this resource. Early engagement and initial enthusiasm have produced many positive outcomes for the healthcare community, but this alone is not sufficient to sustain an increasing role for rural primary care in medical education. The study identified issues that need addressing for sustainability, namely validation, time and costs. Strategies to address these are key to continuation of LICs in small rural communities.

Diabetic foot ulcer off-loading: The gap between evidence and practice. Data from the US Wound Registry.

OBJECTIVE: To evaluate the practice of off-loading diabetic foot ulcers (DFUs) using real-world data from a large wound registry to better identify and understand the gap between evidence and practice. DESIGN: Retrospective, deidentified data were extracted from the US Wound Registry based on patient/wound characteristics, procedures performed, and at which clinic the DFU was treated. SETTING: 96 clinics (23 from the United States and Puerto Rico) PATIENTS: : 11,784 patients; 25,114 DFUs MAIN OUTCOME MEASURES: : Healed/not healed, amputated, percent off-loading, percent use of total contact casting (TCC), infection rate MAIN RESULTS: : Off-loading was documented in only 2.2% of 221,192 visits from January 2, 2007, to January 6, 2013. The most common off-loading option was the postoperative shoe (36.8%) and TCC (16.0%). There were significantly more amputations within 1 year for non-TCC-treated DFUs compared with TCC-treated DFUs (5.2% vs 2.2%; P = .001). The proportion of healed wounds was slightly higher for TCC-treated DFUs versus non-TCC-treated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCC-treated DFUs compared with TCC-treated DFUs (2.6 vs 1.6; P = 2.1 × 10). Only 59 clinics used TCC (61%); 57% of those clinics used traditional TCC, followed by TCC-EZ (36%). Among clinics using any type of TCC, 96.3% of the DFUs that did not receive TCC were "TCC-eligible" ulcers. Among clinics using "traditional" TCC systems, 1.4% of DFUs were treated with TCC, whereas clinics using TCC-EZ provided TCC to 6.2% of DFUs. CONCLUSION: Total contact casting is vastly underutilized in DFU wound care settings, suggesting that there is a gap in practice for adequate off-loading. New, easier-to-apply TCC kits, such as the TCC-EZ, may increase the frequency with which this ideal form of adequate off-loading is utilized.

Development of a wound healing index for patients with chronic wounds.

Randomized controlled trials in wound care generalize poorly because they exclude patients with significant comorbid conditions. Research using real-world wound care patients is hindered by lack of validated methods to stratify patients according to severity of underlying illnesses. We developed a comprehensive stratification system for patients with wounds that predicts healing likelihood. Complete medical record data on 50,967 wounds from the United States Wound Registry were assigned a clear outcome (healed, amputated, etc.). Factors known to be associated with healing were evaluated using logistic regression models. Significant variables (p < 0.05) were determined and subsequently tested on a holdout sample of data. A different model predicted healing for each wound type. Some variables predicted significantly in nearly all models: wound size, wound age, number of wounds, evidence of bioburden, tissue type exposed (Wagner grade or stage), being nonambulatory, and requiring hospitalization during the course of care. Variables significant in some models included renal failure, renal transplant, malnutrition, autoimmune disease, and cardiovascular disease. All models validated well when applied to the holdout sample. The "Wound Healing Index" can validly predict likelihood of wound healing among real-world patients and can facilitate comparative effectiveness research to identify patients needing advanced therapeutics.

Estimating the applicability of wound care randomized controlled trials to general wound-care populations by estimating the percentage of individuals excluded from a typical wound-care population in such trials.

OBJECTIVE: To determine the percentage of individuals that would be excluded from wound care randomized controlled trials (RCTs) as a surrogate for applicability to general populations. DESIGN: A representative sample of wound-care RCTs was selected from the literature in the past 10 years. Exclusion criteria from the trials were evaluated, and prevalence values for each excluded condition were obtained from a large wound-care population, as well as from the literature. The percentage of patients excluded on this basis was calculated. SETTING: Seventeen RCTs testing "high-technology" wound-care products were evaluated. PATIENTS: : Patients in the trials were treated for ulcers (venous, diabetic foot, and pressure ulcers). MAIN OUTCOME MEASURES: A percentage of patients in the study population were excluded for each RCT. MAIN RESULTS: More than 50% of the study population would have been excluded in 15 of the 17 RCTs. When less clinically relevant exclusion criteria were removed, 14 of 17 RCTs would still have excluded between 25% and 50% of the study population. CONCLUSION: The results raise serious questions regarding the applicability of these RCTs to wound-care populations.

The safety of negative pressure wound therapy using vacuum-assisted closure in diabetic foot ulcers treated in the outpatient setting.

The purpose of this project was to evaluate the safety of negative pressure wound therapy using the vacuum-assisted closure (V.A.C.) Therapy System (KCI, San Antonio, TX) in diabetic foot ulcers (DFUs) among wound centre outpatients. We defined events that could represent complications or adverse events (AEs) as a result of treatment with the V.A.C., including symptoms of infection, pain, bleeding and periwound skin breakdown. The frequency of these AEs among V.A.C. patients with DFUs was compared with those among similar non V.A.C. patients. This project prospectively queried data collected during routine clinical care from 16 outpatient wound centres using the Intellicure electronic medical record system. The electronic records were de-identified according to HIPAA requirements and pooled to create a data repository dedicated to research (the Intellicure Research Consortium). Analysis was performed on 1331 DFUs representing 16,438 outpatient visits. A total of 1299 non V.A.C. and 72 V.A.C. DFUs were available for analysis. There was either no statistical difference between the AEs of V.A.C. versus non V.A.C. patients or the V.A.C. exerted a protective effect. We conclude that the V.A.C. is safe in outpatient use.

Limitations of Daily Living Activities in Patients With Venous Stasis Ulcers Undergoing Compression Bandaging: Problems With the Concept of Self-bandaging.

Venous stasis ulcers (VSUs) represent both an enormous cost to the healthcare system and significant quality-of-life issue to patients. While certain high-technology products have shown promise, compression bandaging continues to be the gold standard of care. Recently, some regional Medicare carriers suggested that patients with VSUs should be able to perform self-bandaging in an effort to avoid reimbursing caregivers to provide this service. Using a database of 7251 patients from 29 wound care facilities maintained as part of an agreement under the Intellicure Research Consortium for users of Intellicure Inc's (The Woodlands, Tex) wound care software; activity of daily living (ADL) data was extracted for all patients with a VSU in whom this was collected (547 patients) to examine such an impact. Analysis showed that 55% of these patients required assistance with ADLs-the majority had issues with dressing and toileting. It is unlikely that patients who require assistance with dressing and toileting will be able to achieve adequate positioning to perform self-bandaging. Since it is possible that even patients who do not require assistance with ADLs might be unable to perform self-bandaging, the authors consider these results a conservative estimation. These results indicate that a significant number of patients are not capable of self-bandaging, thus placing their prognosis and quality-of-life at risk if they are unable to pay for the necessary professional services or do not have family members who are capable of bandaging.

A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index.

Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials. Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p < 0.05) and tested on a hold-out sample of data. Out of 13,266 DFUs from the original dataset, 6,440 were eligible for analysis. The logistic regression model included 5,239 ulcers, of which 3,462 healed (66.1%). The 10% validation sample utilized 555 ulcers, of which 377 healed (67.9%). Results: Variables that significantly predicted healing were as follows: wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, patient age, Wagner grade, being nonambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization for any reason. Innovation: We present a validated stratification system, previously described as the Wound Healing Index (WHI), which predicts healing likelihood of patients with DFUs, incorporating patient- and wound-specific variables. Conclusion: The DFU WHI is a comprehensive and user-friendly validated predictive model for DFU healing. It can risk stratify patients enrolled in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require costly therapy to heal.

Electronic Health Records, Registries, and Quality Measures: What? Why? How?

The transition from volume-based healthcare to value-based care is advancing via the reporting of quality measures, initially as a part of "pay for performance" within Medicare's Physician Quality Reporting System (PQRS) initiative. However, "value-based purchasing" requirements within the Affordable Care Act will increase the percentage of reimbursement linked to the reporting of quality measures. Currently, only five PQRS measures are relevant to wound care, and the venous ulcer care measure will be retired this year. PQRS measures in wound care can only be reported via claims or qualified patient registries, and no wound care measures are endorsed by the National Quality Forum (NQF). The recent Health Informational Technology for Economic and Clinical Health (HITECH) Act promoting the adoption of electronic health records (EHRs) requires quality reporting by clinicians wishing to access EHR adoption money. These clinicians will be able to comply with the next stage of "meaningful use" of EHRs, beginning in 2015, by submitting data to a qualified registry, and registry submission may eventually be required by Medicare for reimbursement of some wound care products and procedures. Other specialties are using registries to track adverse events, measure compliance with practice guidelines, and for comparative effectiveness data. Evidence-based measures should be developed as electronic measures that can be submitted directly from the clinicians' EHR. New wound care measures should undergo testing for NQF endorsement. The not-for-profit U.S. Wound Registry is a qualified patient registry that is available for PQRS reporting, measure testing, and future registry submission requirements. The lack of tested wound care quality measures threatens the entire wound care industry, as quality-based reimbursement is not limited to physician payment. Quality measures are an increasingly important part of many Medicare payment systems, including those for acute care hospitals, hospital-based outpatient wound care departments, and accountable care organizations.

Examining the relationship between physician and facility level-of-service coding in outpatient wound centers: results of a multicenter study .

The evaluation and management (E/M) services for the physician and the hospital-based outpatient center ("facility") are calculated using different federal regulations. In addition, patients visiting outpatient wound care centers require different levels of care from the physician than the facility. The purpose of this study was to analyze and compare physician and facility E/M level-of-service coding using the electronic wound registry records from three geographically diverse, hospital-based outpatient wound centers. De-identified data on 9,985 patient visit level-of-service codes were prospectively collected using an electronic health record (EHR) system that internally and automatically audits the chart and calculates the physician and the facility E/M level of service based on the documentation present in the chart. Correlations were calculated using Kendall's tau b/Goodman-Kruskal gamma statistics. Correlations were weak between facility and physician E/M level-of-service codes, varying from 0.084 to 0.179 for follow-up and from 0.066 to 0.354 for initial visits. Although facility E/M levels of service followed a normal distribution, physician E/M visits were heavily skewed toward higher levels of care (3 to 5). These findings confirm that, especially during the initial visit, patients presenting at outpatient wound centers require different levels of care from the physician than from the facility. The finding that initial physician level of service coding was higher than facility E/M levels of service for both initial and follow-up visits is not unexpected, considering the high number of comorbidities in many wound patients and the general risk of their presenting problems.

A retrospective data analysis of antimicrobial dressing usage in 3,084 patients.

Knowledge about practice patterns and optimal usage criteria for topical antimicrobial dressings is limited. A retrospective data analysis was conducted to evaluate: 1) the length of time these dressings are applied in a typical episode of wound care, 2) the number of episodes of antimicrobial dressing use, and 3) whether antimicrobial dressings are applied in consideration of signs and symptoms of infection. Wound care registry data from a level-4 electronic medical record were analyzed, providing information on 3,084 patients older than 17 years seen from July 2003 through December 2008 in 26 hospital-based, outpatient wound centers in 14 states. The 5,541 recorded wounds ranged in size from 0.3 to 225 cm2. One antimicrobial dressing use episode was recorded for 71% of wounds (4.7% had four or more). Mean treatment episode length was 32.5 days (median 21 days). Clinicians used these dressings for a longer period of time if patients had multiple comorbidities (P = .0001), a refractory wound (P <.00001), or were prescribed oral antibiotics (P <.0002); first dressing use was more common in wounds with signs and symptoms of infection (P <.00001). During an average of 16 (median 10) visits and a follow-up time of 269 days, 61.4% of wounds healed (range 42.2% for flaps or grafts to 67.9% for surgical wounds of all 5,541 wounds). Antimicrobial dressing use for 2 to 4 weeks was associated with a higher proportion of healed wounds, but in wounds that healed, longer dressing use was associated with a longer healing time. The practice pattern observed suggests that antimicrobial dressing usage generally is based on patient and wound assessment variables but prospective studies are needed to develop optimal guidelines of care.