EE A New Concept of a Multidisciplinary Wound Healing Center and a National Expert Function of Wound Healing Finn Gottrup, MD, DMSe; Per Holstein, MD, DMSc; Bo Jorgensen, MD; Michael Lohmann, MD; Tonny Karlsmark, MD, DMSe Hypothesis: An independent, multidisciplinary wound healing center in an accepted national expert function ‘of wound healing is the optimal way to improve prophy- laxis and treatment of patients with problem wounds. Design: A clinical perspective analysis. ‘Setting: An independent, multidisciplinary wound heal- ing center focusing on all types of problem wounds, or- ganized as a university hospital department, aid inte- ‘grated in an expert function in the national health care ‘organization of Denmark, Patients and Methods: Patients with all types of prob- lem wounds referred to and treated in the center during the first years ofits existence provided a model for a new rmultidisciplinary structure for treatment of wound pa- tients in the health care system, Results: During the first 3 years of the fully function- ing wound healing center, a total of 23802 patient con- sultations were performed in the outpatient clinic, and 1014 patients with problem wounds were hospitalized in the inpatient ward. The surgical concept of the center hhas resulted in improved healing rates in patients with leg ulcers and decreased rates of major amputations. The futpatient function has resulted in a decrease in the num- ber of patients transported in beds to the center. This struc- ture provides better opportunities for basic and clinical research as well as for establishing expert education for alltypes of health care personnel. The center's structure hhas been the backgroud for establishing an expert func- tion in wound healing, allowing the wound healing area area to be fully integrated in the Danish National Health Care System, Overall, the concept and structure of the center have enhanced the knowledge and understand- {ing of wound problems and increased the status of wound healing and patient care. Conelusions: Establishing multidisciplinary centers integrated into an accepted national expert function of wound healing isan optimal way to improve the elini- cal outcome of prophylaxis and treatment ofall ypes of problem wounds. This model, with minor adjustments, ‘may be applicable for both industrialized and develop” ing countries, Arch Surg, 2001;136:765- ONHEALING wounds area significant problem. The frequency varies, but at any time almost 1% of the world’s population experiences problem wounds, with asso- tured fashion, involving different types of ‘medical specialties and groups of health care workers. Recently, however, multidisc plinary approaches increasingly have been implemented in different countries with varying health care delivery systems." In Us commercial wound centers and wound From the Copenhagen Wound Healing Center, Bspebjerg University Hosp Copenhagen, Denmark ‘eepmnsreD) TREHSURGNOL TS JO aor ciated costs accounting for more than 2% to 4% of health care expenses." Purther- ‘more, patients with problem wounds ex- perience a serious decrease in their qual- ity of life. These factors have led to the establishment of wound healing groups and centers as well as national and inter- national societies worldwide. Problem wounds are defined as wounds that are chronic and resistant to therapy. provide anextra risk, and reduce the quality of le of the patient For many years, treatment of prob- lem wounds was provided in a nonstruc- cate clinics in universities, regimens have been organized," Mulidiseiplinary ap- proaches to wound eare in the primary health care sectoras wellasin hospitals have demonstrated redaction in ome visits and the range of products used" Standardiz- dng the treatment plans seems to improve healing of certain chronic wounds (David Knighton, MD, Wound Care Centers, Minneapolis) Minn, oral communication, 1902) 34 However, the structure of teams oF centers primarily has been geographi- (©2001 American Medical Association, All sights reserved. Downloaded From: http:/jamanetwork.com/ on 10/24/2016METHODS (CENTER ORGANIZATION ‘The center organization canbe divided into the following sim, clinical activity, scientific and educational activity, and integration, Aim of the Center ‘Through standardized wound classification (fable 1) and. diagnostic and treatment plans, the center offers patients. ‘withall types of problem wounds optimal clinical eare and. prophylaxis. The center focuses on basic and clinical r= Search, quality assurance, and edcation fall types of health care personnel, (Clinical Staf and Facilities ‘The center isan independent hospital department funded by the government, and consists ofan outpaticnt clinic and an {inpatient ward, The clnial stall has 52 persons and the r= search stall has & persons. The personnel employed in the center, independent of thei earlier education and specialty, ‘work full-time with patients who have problem wound, eh Matec lt a seal Soc nig neta et iit aR Wp Besides the full-time staf, there are part-time staff Including dieticians, occupational therapists, and social workers Outpatient Clinic, Forty to 45 patients are sen daly in theeutpatient clinic Inthe muldsciplinary team model, all ypesof staf are present simultaneously, allowing op” tinal treatment plans to be produced athe patent nt {al vst A total of9 examining rooms are available. One room is used for patiens invelved in different types of project (eg research related to development af new prod- tts basic science) and I room has special aliies for sur flea procedures that require local anesthesia, Major sur ery wth general aneathestas performed inaceiralsurglel thee, The sal ofthe center performs surgery forall the tients except for specialized procedures such as major ‘ecclar and lanl surgery, which ae performed by Collaborating departments, Once a week, a tompression- SHocking clini with surielapplance makers an once 2 ‘month, a shoe clinic with an orthopedic shoemaker ork swith the centr. ‘Ward. The ward has 20 beds for wound inpatients, and is equipped for the conditions ofthe patients, who often are clderly and immobile Clinical Activity Referral. Patients with all types of problem wounds can be relerred. Referrals come from both the primary and secondaty health care sectors. Patients can be referred to the outpatient clini, while referrals tothe ward must be approved by a physician from the center, The center pei- marily serves the area of Copenhagen Hospital Corpora tion, which has « population of 550000. Referrals from. the remaining population of Denmark (5.5 million Inhabitants), however, frequently are received. Initial Visit The first time patents are seen in the out Patient clinic a complete standardized wound healing Fecord is produced and stored, The record contains the Patients medial, surge socal, and medication history: Fesults ofa complete physical examination; a wound ‘ssessinent and description, general patient information; diagnostic investigations nd retment plan Diagnostic Armamentarium. Based on the clinical exam nation, different types of investigations are used, eg, va ‘ous typesol Dopplerseans,ankle-arm index, andtoe-pressure ‘meastrements. Angiography is used in conjunction with the vascular evaluation. In the United States, ranscutane- tuts oxygen tension is often used as « diagnostic tool in diabetic patients with falsely elevated ankle-arm index.” with values higher than 30 mm Hg indicating adequate UUssue perfuston for healing in diabetes.” The CWHC cally dependent. In most centers, the staff work part. lime in an outpatient setting with patients who have chronic wounds. In case of hospitalization, the wound, patient is referred to specialized department in derma- tology, surgery, internal medicine, oF other relevant de- partment, where the knowledge of wound treatment is limited. (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 TOL e ON mor For these reasons, centralization and standardiza- Lon are important issues in wound treatment and care The ideal concept of a wound healing center should be based on multidisciplinary, well-educated personnel, who work full-time with problem wounds and are able to care {or patients with all types of problem wounds during the entire treatment course. The concept should be part of Association, All rights reserved.uses the toe-pressute measurements as the “gold stan- ddard” of the degree of arterial insufficiency." Transcu- taneous oxygen tension is presently used scientifically but say be a clinical standard inthe fature Improved diagnostic equipment has made surgery & better option for leg uleer patients. Before surgery a du- plex (color) Doppler investigation is performed to inves Ligate superficial aswell as deep venous insulliciencies and visualize insulicient peeforans “Treatment and Further Sirsegy Patients with minor prob- lem wounds are normally seen only once, whereas pa- ‘inte with more compicaad wounds contin tobe rated inthe outpatient clini or, eventually, might be refered to the ward. fllow-up program has been established, and the general treatment plans have been published.” Algo- tihins for management of patients with venous leg ulcers dnd diabetic foot ulcers are shown in Figure Y and Figure 2, respectively Presureulcerare prima rated by the primary health care outpatient function, withthe Principal strategy of relieving pressure and improving the patent's condition?” Prophylactic Activity 1m the Danish health care sector, ispebjerg University Hospital has a special role in prophylaxis, and this is also important in the CWHC, The goal isto keep wound. patients in their normal envionment for as long as pos- ‘ble, Patients with pressure ulcers are often elderly and. fragile, so transport to and consultation in the outpatient clinic poses a major stress, creating « high risk for nev ulcers. To improve prophylaxis and to decrease the fre quency of hospital visits, a primary health care outpa- tient function organized as a quality assurance project, hhas been established. A full-time nurse from the center assists the personnel in 2 of 13 treatment areas of the primary health care sector in Copenhagen. This system, Includes telemedicine, which allows the nurse at one of the areas via the Internet send digitalized pictures of the wounds to a physician atthe center to disewss the treat- rent plan. Inthe future, the intent is to use this outpa- tient function for patients with all types of problem, wounds. The center is also involved in prophylactic investigations directed to better contol of blood ghicose levels and standardized sel[-examination of the feet of diabetic patients, Scientific Activity Inbasc research, the focusis onthe use of animal and hu rman models and techniques to investigate the mechs nisms ofthe healing process» In clinical researc, surgery- related" wovind infections" "and the use of new drugs and bandages!” are top priory. In quality assurance, 3 areas in particular ar of inte est (1) structural problems between the healih care se torsin the treatment of problem wounds; (2) modesto de- Scribe the diferent types of wounds ther clcsificaton, treatment, and prophylaxis; and (3) how to improve the ality of lie fr patents with problem wounds. Educational Activity Internal and external education is ongoing. The results of lintel tals and research achieved inthe center are dis tributed to other areas ofthe health care system, sing the “fey-person” model The center stall edeates spec nuinber of health care workers, who subsequently dissemi hate the knowledge tothe whole health care system ‘Wound healing education is included to minor de- sec inthe preraduate education of medical doctors, Pre- radunte an posigaduate education provided bythe cen- {Gr forall types of healthcare workers. This has been achieved through internal and exteral courses and edi ational dy andl evening arangements "Togefcr with the Danish surgical Society, the center organizes a specialized postgraduate day course on wound ieslng problems. Furthermore a Scandinavian multi ciplinary 3-day course for health care staf working with ‘wound patients hasbeen organized once a yar forthe ast 8 years The numberof parilpants limited, allowing in- tensive discussion. The course is supported by the indus try involved in producing wound:-elted products, ands sm exampe of ow the health care system andthe indus try can work together nan objecive way In cooperation withthe Danish Nurs Astociaton, the center conducts a centralized wound course for nurses en- tied “The Longer Posigraduate Cours for Nurses Work ing With Wound Patient” 1 consists of 4 modules, cach lasting for week, Between the modules, the participants have homework and, atthe end ofthe course, each par Atapant produces amajor report ona specie wound prob- lem The report is graded and isan essential part ofthe course. The partilpants obtains diploma and the cert Cation of "Norse Specialist in Wound Healing” This al lows negotlation for specific employment and increased slaty, Based on the achieved experience ofthe courses government-supported diploma education is planned for freee in wound care INTEGRATION OF THE CENTER IN A NATIONAL HEALTH CARE ORGANIZATION 114s ital that an expert function in wound healing be- Comes an independent and integrated function of coun- try national Healthcare system, The funtion should be bieed on a mulidiseiplinary approach, which would be- come an expert area rather than a specialty, The function imDenmark has been called clinical wound healing, ‘an expert function in wound healing, which is an inte- ‘grated part of the national health care system. The idea of a wound healing center in Copenha- igen, Denmark, was generated in 1991 after the creation ‘of a professorship related to wound healing. The early center function consisted ofa research unit with monthly clinical conferences between senior physicians in dilfer- (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 TROL sO mor ent specialties discussing patient cases of problem wounds.» General problems in wound treatment and pa- tient care were determined tobe lack of standardized treat ment and referral plans; lack of multidisciplinary col- laboration; lack of evaluation plans ofthe given treatment; lack of knowledge of health care personnel, patients, and administrative persons; lack of treatment structure for Association, All rights reserved.‘Table 1. Classification of Wounds by Cause Casati Tipe or wounes ‘Wounds redo changes Atari [achemie) wounds invessels \eraus wounds Lymphate wounds Wounds raed 0 Dabee wounds reropahy Ache wounde (ter neuropathic wounds Wounds raised 0 Pressure ler deci) pressurelicion Wounds rl fo trauma ae suger) (tginalycontanintd wounds (surgery related to intra organs) Cngialy clan wound (evgey related to bone) Speized wounds (surgery eld to lat eurgey) nora tle Stoma-lte wounde Spec infection wounds (a, AIDS) Nogpatic wounds Vareuli wounde Cer inammaony wounds Wounds inte ara caiy Slt mutating wounds ypergranuling wounds and Ids (ther typs of wounds “ADS indatesaequired immunodetiieney syndrome = ‘Wor Minas figure +, Agr for Wesel venous fp ler in th Copenhagen Wound Healing Cntr the patients; and lack of baste and clinical research, A si- rmultancous investigation of the primary health care sec- tor in the central part of Copenhagen documented the following problems": in patients with chronic wound problems, only 51% had a significant diagnost nation; 40% of patients with expected venous leg ulcers (eepansreD) TREHSURGNOL TS JO ior (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 Figure 2. Agari fr venimet of abate fot problems in Capenhagan Wound Heaing Cente hhad not been treated with compression; 34% of patients witha foot leer were not investigated for diabetes mell- tus; and only half of the patients with a pressure ulcer hhad any specific, organized relieving treatmes These early conferences resulted in an agreed strat- egy, which, when implemented, led to an improvement of the healing in more than half the patients classified as “nonbealers."® A diabetic foot clinic was simulla- ncously established at the hospital. Following the duction of arterial bypass reconstruction in distal pedal arteries and specific local wound care, the number of ma- jor amputations was reduced significantly." In 1995 {o 1906, the structure of the hospital system of central Copenhagen changed from having 7 separate hospitals to having a single central hospital organization (Copen- hhagen Hospital Corporation) with 5400 inpatient beds. The early wound healing center and the diabetic foot clinic joined to form the Copenhagen Wound Healing Center (CWHC) in 1996, The center is an independent, clin cal multidiseiplinary department that treats all types of problem wounds and is housed in the Bispebjerg Uni versity Hospital. Since March 1007, the center has been fully functioning after a stepwise start during the first months The aims of this article are to describe the estab- lishment of this integrated wound treatment organiz on in the Danish national health care system, and toe plain how the model might be applicable for both industrialized and developing countries ES} CLINICAL ACTIVITY During the frst 3 years of full eapacity, 23802 (approxi- mately 8000 per year or 1400 per 100000 inhabitants) consultations have taken place in the outpatient clinic and 1014 patients (approximately 340 per year) were re- ferred to the inpatient ward. The distribution of outpa- jents and inpatients by years is shown in Table 2 and by causes in Table 3, The duration of the wounds was froma few months to several years. The total number of patients treated in the outpatient clinie was 45% of the Association, All rights reserved.‘Table 2. Number of Outpatient and Inpatient Consultations ver outpat pationt Ward ioe? Tet 27 1908 Tea 388 1900 083 382 ‘Table 3. Causes for Inpatient and Outpatient Contacts oy inpatient Ware eu igus s B Diabet les 55 2 Pressure sree 1 6 isalanenus® & 2 ‘lal 100 100 “tous problem wounds ih nlc, ile, pllondl nus, and oe race wounds ols the total number of consultations for which reason each pa- tient visited the center approximately a mean of 2 times. ‘Of hospitalized patients, 17% to 18% had been hospital- ized before. The mean slay at the department was 16 days. Most referrals came from the area of Copenhagen Hos- pital Corporation (84%), while 16% came from other parts fof Denmark TYPES OF ULCERS. Leg and foot ulcers in patients without diabetes account for 53% and 38% of treated ulcers in the outpatient and Inpatient clinics, respectively. For almost al patients, the wound has been treated several times outside the center without healing. Venous leg ulcers are treated with astan- dardized conservative regimen, consisting of a local reat- ment of the wound area and compression bandages pri- marily with 2 layers. If patients receiving this regimen show no improvement after 3 months, they are offered surgery. Approximately 15% of these patients have iso- lated superficial venous insulliciency and 85% have deep or combined deep and superficial insulficiency ‘Occluded deep veins, which are rare, are an absolute contraindication for surgery, but deep or combined deep and superficial venous insulficiency is not contr indicated The standard surgical procedure used is excision of the wound and adjacent pathological tissue (ipo- dermatosclerotic skin), split-skin transplantation, and, ifnecessary, venous resection and perforantectomy. All patients use compression bandages postoperatively Results from the initial 53 patients with nonheal- ing wounds are shown in Fable 4. The reasons for re ‘currence of venous ulcers were infection in more than half the cases, while insufficient compression ae- ‘counted for one third. Economic analyses have shown, ‘cosl-effectiveness in cases of no recurrence at 10 months alter surgery of venous leg ulcers, in relation to the ex tra expenses of the surgical procedure (ie, the extra ex- penses of surgery are similar to the rate of expenses of local wound treatment, dressings, ete, alter 10 months) ‘eepmnsreD) TREHSURGNOL TS JO aor (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 Table 4. Standardized Surgical Treatment of Ina 53, lents With Nonhealing Leg Ulers (Early Results) ‘pe etwoune Wo, Rovurene ate ne (2) Venous og ear a 913) Atal leg ies 4 1 (33) Combine eg ules 10 560), Traumatic lg ulcers 8 0 Ober eauset 11 55) Teta Py aco) is dled as anew wound regards fs) a he lace of year Only 108; ulcers ecuredaasimiar seas belore fea cas found that 60% of patients with nonhealing wounds were healed 12 months a Ischemic Ulcers Without Diabetes In patients with gangrene after vascular reconstruction oF those who did not receive vascular surgery for tech- nical reasons, different types of treatments, such as local resection, vacuum-assisted closure, larvae, hyper- baric oxygen, or induced hypertension, have been used. Diabetic Ulcers In the ward, 55% of the patients had diabetes, and this group was the second largest in the outpatient clinic Go). If vascular surgery was needed, the patients were referred to the collaborating vascular department and returned to the center on day 4 or 5 postoperatively Uf vascular surgery was not possible, the patients were treated locally and closely observed for occurrence of fschemia. These patients ate offered hyperbaric oxygen treatment. To investigate the treatment outcome, this Uweatment is organized as @ randomized trial. Almost all inpatients with diabetic ulcers are treated by minor sur- gical procedures (revision, debridement, correction of deformities, etc) using regional anesthesia. Minor ampu- tations (on the foot) were performed in the center, while major amputations (below or above knee) were done by the orthopedic department. A combined use of the deseribed procedures has decreased the major amput tion rate for these patients to approximately 20% of that 10 to 15 years ago."""" Pressure Sores (Decul us) In the outpatient clinic, 6% of patients had a pressure ul- cer in the hip-sacral region. This low number is a result of the center's policy of treating the patient in the home as long as possible. The primary health care outpatient function has significantly supported this strategy, and the preliminary results seem promising, The incidence of pres- sure ulcers in Denmark is not known, but probably un- derestimated. Before starting the outpatient project, the estimated number of persons with pressure ulcers in the area was close to zero. During the first year of investiga- on, however, 91 patients have been treated for pres- Association, All rights reserved.Figure 3. Model erganaaion of narpart uncon n wound hing and ae clea wound healing’) Asters cles th tha mulisepnary ‘our healing team includes! group fr ea geographic repo inthe Fel care spe i Denmark for sazh “antar)and cana o! ‘pecaldeducsted physica and muse tm Both primary hosp sectors. sure ulcers. The number of bed transports to the center hhas decreased to less than half (40%) after this function started. The need for visitsin the outpatient clinic for these patients has consequently decreased, ‘Other Types of Wounds Although most chronic problem wounds are treated in the center, many patients with acute surgical wound prob- lems have been treated atthe parent unit. The center then assists the stalf during the continuous treatment of the patient. SURGICAL ACTIVITY During the last 2 years, surgical treatment has contin- uued to increase; 250 surgical procedures using general anesthesia and 270 using local anesthesia wei formed, per INSPECTIONS Inspections of wound patients in other departments have been provided when transport of the patient to the cen- ler was impossible, In 1099, a total of 377 inspections ‘were carried out in other departments. Once a week, the center conducts inspections at 2 other hospitals to evalt- ‘ate patients with problem wounds related to vaseular and diabetic problems, SCIENTIFIC ACTIVITY ight full-time researchers (4 nurses), a technician, and several partime researchers are affiliated with the cen- ter, Laboratory facilities have been established outside the center allowing basic as well as clinical research, Laboratory facilities related to the center have now been cestablished. In the centers first year of full operation, (2998), research activity resulted in the publication of 25 articles, 18 abstracts, and 51 presentations of scien- tific lectures. The center has, since its start, been involved in 6 trans-European and several Scandinavian and national clinical projects, (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 TROL sO mor EDUCATIONAL ACTIVITY There hasbeen increasing educational activity since the start. of the center. In 1998, this activity resulted in 46, 34, and 10 educational presentations of medical doctors, nurses, and podiatrists, respectively. The centralized wound course for nurses, "Longer Postgraduate Course for Nurses Working With Wound Patients,” has been offered 5 times, with more than 130 nurses having completed the course. At present, a centralized wound healing course for all types of surgeons is being planned as the first phase of more generalized education in wound healing for physicians. INTEGRATION OF THE CENTER IN A NATIONAL HEALTH CARE ORGANIZATION A proposal for an expert function (called clinical wound hhealing) has been submitted to the Danish National Board of Health. The plan is based on 2 important issties: of- ganization and classification of a new structure for edu- calion of stall to get acceptance as an authorized wound healer. The organization of this function is done in col- laboration with the Danish Wound Healing Society, which hhas 1000 active members in the health care system. Con- tacts with the national societies of each medical spe- cialty working with wound problems have been estab- lished to geta general agreement of the structure of this expert function. The model for this structure is based on the exist ing structure ofthe health eare system, but with new. ements focusing especially on problem wounds (Figure 3). The health care system in Denmark is di- vided into 14 regions (amter), each having a separate economy in relation to health eate expenses. It is pro- posed that in each of these regions (amter), a standard- ized multidisciplinary wound healing team, consisting, ofa local stall, be established. This has already taken place in some of the regions. The team should be the referral organization for wound patients in the local region and should organize the plans for treatment in the primary sector as well a in the local hospitals. ts expected that with this approach most patients with problem wounds can be healed. However, a few patients will need more specialized treatment in a centralized wound healing center. In countries the size of Denmark (5.2 million in- hhabitants), 1, pethaps 2, specialized center probably will fulfill this need. Since the wound healing teams also take care of diabetic foot problems, the survival of dia- betic foot organizations might be secured this way in the future. ‘An important part of this structure is the educa tional plan for the staff, which includes the following: “+ Nurses: pregraduate and postgraduate education plan {s established in the CWHC. The postgraduate editea- tion, including the longer postgraduate course, must be extended to develop a specialist nurse function el- theras a specialist degree of acheiving a diploma from the Danish National Board of Health + Physicians: No standardized pregraduate and post- graduate education is established outside the center. Association, All rights reserved.‘A-level competence model is proposed. Level Lis ba sic education of all specialist physicians. The educa tion is primarily theoretical and should be included in all specialist programs. Level 2 includes education for physicians in wound healing teams and in specialized hospital departments treating problem wounds. The ‘education is both theoretical and practical. The prac ical part should last at least 12 months and take place in a specialized wound healing center. Level 3 is edu- cation for specialized physicians employed at wound healing centers. The education has a theoretical and practical part, of which the latter should last at least 24 months. Twelve of these months should take place ata specialized wound healing center, and the remain- ing months in a selected specialized relevant depart- ment [or treatment of problem wounds. The theoreti- cal part of levels 2 and 3 includes a specific number and type of courses covering the wound healing area When the education has been completed, the phy- sician should receive the degree, “Wound Healing EX pert of Fitst or Second Degree,” and attain a diploma from the National Board of Health, which provides the gradu- ate opportunities for employment preferencesand ahigher salary —_1KIiZ:n”m”_—_@y_§_ Different concepts for the treatment of problem wounds have been created during the last 10 to 20 years. Most models have been based on an outpatient clinic related toa specialized department, such as plastic, orthopedic, cor vascular surgery, or dermatology. These clinies ust ally function 1 to 2 days a week and focus on a specific type of problem wound, such as diabetic foot ulcers, ve- nous leg ulcers, or pressure ulcers. In this article, we have described a new concept of a wound healing center and ‘organization of an expert function in « national health, care system. The wound healing center is multidise- plinary and independent of the medical specialty sys- {em and organized asa normal university department with both outpatient and inpatient facilities that focus on all, types of problem wounds, The CWHC in Denmark is the key element in the national expert function integrated in the Danish national health care organization, The establishment of CWHC has been a successful venture. The number of referred patients has been sig- nificantly higher than expected and most patients have required multiple services of the hospital system, These services have been accomplished in the center regimen due to the multidisciplinary setup. Despite being con- sidered “nonhealers” for years, most patients have had successful healing after being referred to the center. We have reported healing in more than half the cases, when an agreed multidisciplinary strategy was used,” and an improvement in patients with all types of problem wounds.” Little evidence for the healing rate of standard- treated problem wounds is available in Denmark and other ‘counties. The explanation may be thal there are no ac- cepted, specific standardized treatment plans. This means that no comparable baseline healing rate for the diller- (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 10/24/2016 ent types of problem wounds exists, A standardized, ac- cepted treatment plan for each type of problem wound fs therefore essential. This can best be provided through ‘a multidisciplinary approach in a national structure that provides generally accepted guidelines. Using the multidisciplinary center concept de- scribed in this article, itis possible to organize standard- ted diagnostic and treatment procedures and provide guidelines for treatment plans that can become ac- cepted nationally. The structure of the center is compa- rable toa department of a university hospital anywhere in the world, but different from all types of wound heal- ing centers. This type of center concept should also be able tobe accepted asa national expert function in wound healing. Why choose a full department structure and why treat all types of wounds in such a center concept? The advantages of having a full department containing both fan outpatient clinic and inpatient ward and staffed with employees who work fulltime with problem wounds are (1) development of standardized treatment plans; (2) access to relevant objective investigative methods, and relevant surgical approaches; (3) higher degree of continuity in treatment; (4) treatment plan based on a multidisciplinary assessment; (5) treatment plans at the initial visit; (6) increased patient satisfaction; (7) im- proved possibilities for education and training ofall types of health care personnel; and (8) improved possibilities for basic and clinical research in healing and care of patients, The idea of treating all types of wounds at the same place is based on the following considerations: (1) wound treatment, especially provided locally in the wound area, 1 similar forall types of wounds; (2) the staf learns the natural history ofall ypes of wounds; (3) treatment plans for different types of wounds will be identical; (4) the resources and the diagnostic and treatment armamen- tarium will be used optimally; (5) focusing on all types of wounds allows an independent national expert fune- tion to be established; (6) status of all types of wound treatment is increased: (7) secure education is attained; and (8) cost-effectiveness of treatment is maximized Les} This article describes 4 new concept to organize treat- ment of wounds locally and nationally. A wound heal- ing center consisting of an independent, multidisei- plinary department integrated in national expert fanction fs beneficial to patients and society. A setup with person- nel working full-time with all types of problem wounds {improves the compliance and continuity of treatment and care and provides access to relevant diagnostics and thers- peutic measures. Also, the possibilities for education of health care personnel, as well as research, are improved. This model, with minor adjustments, maybe applicable for both industrialized and developing countries Corresponding author and reprints: Finn Gottrup, MD, DMSc, Copenhagen Wound Healing Center, Bispebjerg Uni- versity Hospital, Bispebjerg Bakke 23, DK-2400, Copen- hhagen NV, Denmark (e-mail: fg02@bbh. hosp. dl) Association, All rights reserved.ss} Andeson Hansson, Suabeck 6. Lega foo ules an pdenaegia survey ete Do Vata! Supe (Ste) 80486227202 Diled vai ero eg: sty of he prevalence in Seth Cam sniy eatn Bul an). 198841310-316 Uae. Lg Ur Patents: iia Sues rom Prevalence Pevenon [thes Lane, Sweden: Lands ier 19, ‘ren AL Chang’ Malin OS Thal oat oe ule hoepatbves aut I Procecngs che usa neszonl Wound Maragement Con {err re 884; Meboure, usta Pape 251259 Gott F, Aj 8, Tyla iorat en nik uring, Medst Atop hsp abana 98533-6 ‘otpF Sting ups woud hey cnn Copenhagen Prin rn 1988 e228 monde ME Btn UP, Mor ME Thomas EM, Coton LT, Wai Pn. proved sural of he abe et theo spacial coi ‘nees0 760771 ons JRun Teal 6 PassonU, Lasson Debi! vets ‘naruiideelngy sting an earamicanyate ofprinay eng sea ing mith anpiain Jnr Meg 196285480-471 Rabson UC Commuicaann mprovng heart heed anrack cancer team. Pls Recon Sug 157661112 Fubson UC Atime oineraethe comple woud ea: am bach a bet ‘ede and baja. Wound Rep agen. 19864187188, rani @ Saando Jones, Crd Wan SBP. Prac ude nes ordevopng hosp based woud an esony elie Wounds 187; 10, Eel A, Mensa P, Ei. Dili uee tan ance. Mound Rapa Ree. 198677-16 Got Prevertonelsugeswourdinacton ela. 2000 1202.08. Keyser E Dabs wounhaing andlin ahopen an client woundcre poo. South eg. 198836311-317 Send OL canton Moos HH, Web WW, xgnestn an devsepent fants muliiplnary wound ee cle. Suga, 109311477579 Ennis Wd, Meneses P Managing wounds ne marged car ervionmen: he ‘trad ones. atny Hound ang 1908442226, 2831, 36 Fas RS rstberqJA Woundexra cress ce ance Ad Wound (Ge 18985012147 Eagle M. Eaueaton for Mase by Muses: Poceedigs afte Tid Erpean CGooerece on aces in Wound Maraganen Londen, England Weems Pblihing Co e196 150-10, Dae Slomon J, Fearn SF. Armuticpinay soposho wound ‘end Car 19345:20- 282 icigtn DR. res, Feel VD, ebumerh, BuierE Cara F Smut ot ‘spar meen nosesng eataenus eu pelt eed wounds in lrmua Sug Gynecol Cost 1990175660. ‘ied DL Cliclerustin ofrcombinan human pallet eves pom {afr ha eaen olowe nomi eae us. J Vase Su. 198521 18, ‘Gotu Wound exer and care hap hatheae Europe 188200 Hope pi of eEurope a) tence oo Laden, gad Camp on Puaising Ld 10993731 KalehaveF Bak E,GotiupF. Organisation and Development of 2 Mu tipinay Wound Ca Unt nCapentagen: Pinna sus: Procesngs 0) Fourth Epes Cntence or Aaanes in Wand Uanagemn Loon, Engl: Maclin Publishing Oo i; 185113-115. estergud Holanda, lak E,Gttup.Sabehandig i hiemmepen, Sjoejarsten 1008983036 ramen graven a a1 2 2 2 (nermnsrep) SRCTSRGNOL TS JO To 25. Hoein,lsgaa,Srase Sea. Anputtantaterensn hos dite arrears, Nore 8061 142-14 Hoste PE Srecen Lino eg experience in amattipowydbac Tost ut. Datta Cae. 1888 2(spp 2857-8108, Hosen, Eisgave Ose 88 EtsgandV.Deoesng cence ot majr ‘mpuaions pple th dabtes. Dbftpe 200043 84-87. tua The Mound Heng Ctrl Copnhapsn Hasta Capron (Ce ennapen Wound Heng Cat), ETAS Bul 00624142 Got Modes wound eamart Nord Med 1996-111.195-98 Batra Shtit PMs oxygen ar bec moun. li Pala Me Sug. 08512106117, Hoste, Lassen NA Hasing of ules onthe eet cordted wih stalled resi mesmo ets sae Ate Oop Sean. 180; 51995-1008, Hate. Te dtllod pressure predesesigol amputations onthe. ‘eta Ota Scad 19843520725, Karate, Wesnind J Holtein Prone rt coast inde Inger rd Vae Enna Surg. 146 1.7677 bret $2, Henkeen olen PE Minar ampuatnsin htt ater tevzedaaion ogg, Acta rap Scand 19 8.20120, Gttup F Olsen Las Si Bagrund lane og bebanang. Copenh en, Denmark Munksgaard lla Pubihes i: 1086, ngesen LN, Kalonarer Kara. Vligad GL, Gatrup Eun ine wound ang pent in onan eng rom the subenesusistion st exuded potatoes uber ameodsag sl. Wound Re ar Rage 109422030, “Tergseen NOt Kallhae ta Themoun hing proces insur babes xautedy te expanded oratory athe poli ah pgs: acoparcon wens elecso napa rail, Wound apa Ran 198 527 52 Loven alee. eines, Krigge low J. GtiupGetancn ances in human stetneous tee Antinrb Agents Chen, og 0-75-1789, Gtup FPhyscgy aed pahophyslgy of wound hen: in vo model. Irepeson8 Anima lode i Si Race tae, te Nh tad: Hawous Meenas 1982005, GotupF Lorenzen Jorgensen LN Human mods. Mani Fabs, Shetman CP, Sandeman 9, ed, Cron Wound Heaig: Cnc! Mesure mets td Bsc Scece Londo, Egan: WS Suncer Co; 99016168 tua, Agren SKasarrt Ta fr ae nwouna ding eek & fury eusng on mira nin as is, Wound Rep agen, oa 8836 ngesen LN, Kalle FChisensen , Sara JE, Gt Fes eogen boducton amok. Surg. 198 25450-455 yen, dorgesen LN araesn Mian Grup Fan mtalope teas vel pede optima ealgee epson dung ety wound ep n amare 87S. 10983588. dngesen LN Kalehare F Kasmas Gatun F Les colignsecumulaon ater mao ergy Surg 1906 80760 15 GotupF Sugealteunerathvoicaguees estat. Wound epi Re en 2000805 KaehaeF MoesgsrdF Gotu Topical anes usedin te tesmet ot ompor wounds 1 oun Ce 1965158-180. Seulze Andee J Orgad He Etec predislon nthe 5s: teierespanse ard wound alg acl surgi. Ach Sr. 887: 122: ras Holm C etaren JS, Grarbek F Gotup Fes oe an comer "eal gauze tessigs ot incon henge boning aprons. Fur J Sug 1085 184179185, Dupo Apeusl, sands ME et ot on ahs nthe tmnt neuropaie det oo lose, Wound Rap ep 2008492, * a. EY a 3» a 2 a a 8 an. a " 0 2 4 4 6 “ a. 4 4 (©2001 American Medical Association, All sights reserved. Downloaded From: http:/jamanetwork.com/ on 10/24/2016