Critical Advances in Wound Care

1. Critical Advances in Wound Care

2. Disclaimers 2

3. The CWI Program endeavors to develop an integrated approach to wound healing encompassing wound-to-rehabilitation strategies in order to provide the best possible care for our service personnel. Serve as the fundamental proving ground for specific advanced wound-related technologies and therapies. Identify mechanisms and predictors of wound healing based on studies of the systemic inflammatory cytokine and chemokine landscape in blood, local wound effluent, and multi-gene expression profiles of wound tissue 3. Develop a wound bio-repository of serum, wound effluent, and soft tissue for translational research in core labs 4. Develop predictive models and decision support tools for personalized care 5. Private � public partnership and national leadershipThe CWI Program endeavors to develop an integrated approach to wound healing encompassing wound-to-rehabilitation strategies in order to provide the best possible care for our service personnel. Serve as the fundamental proving ground for specific advanced wound-related technologies and therapies. Identify mechanisms and predictors of wound healing based on studies of the systemic inflammatory cytokine and chemokine landscape in blood, local wound effluent, and multi-gene expression profiles of wound tissue 3. Develop a wound bio-repository of serum, wound effluent, and soft tissue for translational research in core labs 4. Develop predictive models and decision support tools for personalized care 5. Private � public partnership and national leadership

4. Background: Un-met need for comprehensive, centralized, outpatient complex wound care and limb salvage within the Military Health System Driving policy: Integrated state-of-the-art care for wounded warriors and beneficiaries with acute and chronic wounds Benchmarks: Multi-disciplinary team established and clinic launched at WRAMC and NNMC March 2008

9. Once this paradigm is transported throughout the NCA we would expect the same net reduction in purchased care Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s Once this paradigm is transported throughout the NCA we would expect the same net reduction in purchased care Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s

11. CLINICAL: Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s EDUCATIONAL: Establish center of excellence for wound healing education through DoD/VA wound course Deployment wound care education Educational opportunities for nursing, house staff, and students Prevention of pressure ulcers in OIF/OEF and beneficiaries through joint policy development and education RESEARCH: Shift from �eminence-based� practice to �evidence-based� practice Advancing wound healing science for combat casualties and beneficiaries Reduced time to healing, rehabilitation, and RTD Improved wound-related pain and quality of life Reduced fiscal outlay through focused, resource utilization prudent treatment STANDARDIZATION: Standardized wound, ostomy, skin care product lines Availability and continuity of goods and services Reduction in costs Facilitate education and training Future: Standardize wound healing devices and modalities WRAMC, NNMC, WRNMMC, and throughout DoD CLINICAL: Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s EDUCATIONAL: Establish center of excellence for wound healing education through DoD/VA wound course Deployment wound care education Educational opportunities for nursing, house staff, and students Prevention of pressure ulcers in OIF/OEF and beneficiaries through joint policy development and education RESEARCH: Shift from �eminence-based� practice to �evidence-based� practice Advancing wound healing science for combat casualties and beneficiaries Reduced time to healing, rehabilitation, and RTD Improved wound-related pain and quality of life Reduced fiscal outlay through focused, resource utilization prudent treatment STANDARDIZATION: Standardized wound, ostomy, skin care product lines Availability and continuity of goods and services Reduction in costs Facilitate education and training Future: Standardize wound healing devices and modalities WRAMC, NNMC, WRNMMC, and throughout DoD

12. Development Of The Program 12

13. The familiar sequence of wound healing�.the speaker can suggest that the inflammatory phase is prolonged in the chronic wound.The familiar sequence of wound healing�.the speaker can suggest that the inflammatory phase is prolonged in the chronic wound.

14. More slides to follow on DIME. There are many of these slides, clearly the speaker should choose which slide is the most appropriate given the nature of the audience.More slides to follow on DIME. There are many of these slides, clearly the speaker should choose which slide is the most appropriate given the nature of the audience.

15. Identify Problem Wounds Early And Transition To Advanced Therapy �Good� Wound Care History Assessment Debridement Warm, Moist Environment Offloading Topical Care Advanced Wound Care Hyperbaric Medicine Growth Factors Bioengineered Alternative Tissues Negative Pressure Therapy Biologic Dressings Active Topicals Plastic Surgery Curative Surgery

16. Key Factors Leading To Failure to Heal Underlying pathophysiology: venous and/or arterial insufficiency, diabetes and neuropathy, prolonged immobilization Infection or high bacterial colonization Immunosuppression Concomitant disorders Nutritional deficits Adverse effects of medications on the healing process Key Factors Leading to Failure to Heal Chronic wounds represent a failure or delay in the natural healing process. Chronic wounds either do not pass through the normal, orderly, and timely sequence of repair or they pass through the repair process but normal anatomy and function is not restored The underlying pathophysiology must be recognized and treated when appropriate Key factors are listed aboveKey Factors Leading to Failure to Heal Chronic wounds represent a failure or delay in the natural healing process. Chronic wounds either do not pass through the normal, orderly, and timely sequence of repair or they pass through the repair process but normal anatomy and function is not restored The underlying pathophysiology must be recognized and treated when appropriate Key factors are listed above

18. Complex Wound And Limb Salvage Center Inpatient Care- NNMC, WRAMC All aspects of treatment- ostomy care, war wounded, intraoperative consults, pressure ulcers, acute and chronic wounds Collaboration with inpatient teams is essential Education for the inpatient staff also critical for improved outcomes Procedures/care done at bedside, in the PACU or in the OR

19. Outpatient Care Outpatient Care-NNMC/WRAMC Over 400 patient visits monthly Co-treatment with PT/OT in the MATC Advanced wound care treatments and modalities used Standardization of wound care, ostomy, skin care and cleansers is key Major improvement in the �standard of care�- i.e. wet to dry is NOT standard anymore

20. Advanced Wound Care Products And Modalities Silver based dressings Honey dressings Atraumatic dressings MIST Ultrasound Qoustic Debridement Ultraviolet-C Therapy Scar Treatment Lymphedema care 20

21. Wound Dressings-Current State Of Affairs 1 of the greatest and most confusing challenges in wound care Over 3000 wound dressing products Over 30 different dressing categories Inappropriate dressings can lead to a delay in wound healing Many dressing choice strategies exist and have merit; the clinician must choose which to use.

22. Which One Is Best?

23. Standardization Ostomy Supplies Wound Care Cleansers Skin Care Developed with SME and contracts established with wound companies Education to the inpatient units commenced

24. WRAMC and NNMC have standardized the following product lines: Wound care Ostomy Skin care Wound care products to the operational environment Wound care devices (NPWT) throughout military medicine (with DMSB) Beds and support surfaces WRAMC and NNMC have standardized the following product lines: Wound care Ostomy Skin care Wound care products to the operational environment Wound care devices (NPWT) throughout military medicine (with DMSB) Beds and support surfaces

25. The Use Of Honey � A Historical Perspective  2000 year history Smith Papyrus (the world�s oldest known medical document, 4,000 yrs old) honey mixed with grease and lint to keep it on the wound Aristotle 2 millennia ago some honeys are better than others for use in wound treatment Usage declined at the introduction of penicillin in 1940�s

27. Silver Modes Of Action

28. Wounds Of War- Straightforward

29. Lateral Leg / BKA Wounds

30. Anterior Thigh Donor Sites

31. Antimicrobials And Absorptives

32. Left Lower Extremity

33. Dressings- Mepilex Ag And Acticoat

34. Final Dressings

35. MIST Ultrasound Generator MIST Applicator Kit Applicator Normal saline Antiseptic wipes Absorbent pad MIST Ultrasound Healing Therapy Introduces the MIST System. Includes the ultrasound generator and disposable applicator kit. Introduces the MIST System. Includes the ultrasound generator and disposable applicator kit.

36. How Is MIST Therapy Different? Low frequency, low intensity ultrasound 40kHz Noncontact The only ultrasound device cleared by the FDA to promote wound healing MIST therapy is unique in that it uses a low-frequency AND low intensity ultrasound. Other types of ultrasound used for imaging, sports medicine debridement use contact and a different combination of frequency and intensity. The ultrasound waves of MIST Therapy provide just enough mechanical force on the cells to stimulate without causing damage. The result is accelerated healing. MIST is the ONLY ultrasound device cleared by the FDA to �promote wound healing� and it is not limited to a specific type of wound. It can be used for all wound types throughout the healing process. MIST therapy is unique in that it uses a low-frequency AND low intensity ultrasound. Other types of ultrasound used for imaging, sports medicine debridement use contact and a different combination of frequency and intensity. The ultrasound waves of MIST Therapy provide just enough mechanical force on the cells to stimulate without causing damage. The result is accelerated healing. MIST is the ONLY ultrasound device cleared by the FDA to �promote wound healing� and it is not limited to a specific type of wound. It can be used for all wound types throughout the healing process.

37. Wound Healing Adjuncts Bioengineered tissues Acell Rebuilding of severed digits Apligraf/Dermagraft Grafts from neonatal tissue Integra Tissue scaffold, collagen matrices

38. Advancing The Science Advancing the science of wound healing within the military healthcare system requires more than a multidisciplinary team using advanced technology. It is requisite that we collaborate, employing a Joint effort throughout the continuum of care, that we disseminate knowledge through education, and that clinicians and researchers collaborate in translational research. 38 As Kara has mentioned the CWLSC is much more than an outpatient wound care clinic or an inpatient wound care service providing state of the art care�it is a complex program focused on advancing the science of wound healing, disseminating wound healing knowledge, and establishing efficient business practices throughout the military healthcare system. To be successful we must engage a Joint effort throughout the continuum of care, collaborate with research organizations, and we must ensure that this knowledge is disseminated throughout the MHS. As Kara has mentioned the CWLSC is much more than an outpatient wound care clinic or an inpatient wound care service providing state of the art care�it is a complex program focused on advancing the science of wound healing, disseminating wound healing knowledge, and establishing efficient business practices throughout the military healthcare system. To be successful we must engage a Joint effort throughout the continuum of care, collaborate with research organizations, and we must ensure that this knowledge is disseminated throughout the MHS.

39. Advancing The Science Evidence-Based Protocols, Performance Improvement, and Research Development of clinical practice guidelines Trialing and evaluating promising wound healing therapies Donor site management research project Close relationship with researchers Wound education research grant proposal 39 We are engaged in the development of EBP protocols and CPG�s. We are a central focal point for wound care patients, and our providers see multiple wound types over the healing continuum enabling us to identify effective wound healing modalities. This knowledge we pass on to other areas through collaboration, education, and through wound care formularies. Currently we are developing a donor site management study that will allow us to identify the best practice for this complex and frequent wound type. We work closely with researchers to identify research questions applicable to wound healing and are a medium for wound healing subjects. We are engaged in the development of EBP protocols and CPG�s. We are a central focal point for wound care patients, and our providers see multiple wound types over the healing continuum enabling us to identify effective wound healing modalities. This knowledge we pass on to other areas through collaboration, education, and through wound care formularies. Currently we are developing a donor site management study that will allow us to identify the best practice for this complex and frequent wound type. We work closely with researchers to identify research questions applicable to wound healing and are a medium for wound healing subjects.

40. Advancing The Science Recent injuries MOI: Dismounted IED High bilateral lower extremity amputations +/- vascular injuries Associated open pelvic ring injuries Associated pelvic floor/perineal ST injuries Associated UG injuries High risk of intra-pelvic DVT / PE 40 I do not use this image for shock and awe, but to demonstrate the recent injury types and the complexities associated with them. As you can see these are: -High AKA injuries with significant STI to perineal region requiring fecal diversion -They are heavily contaminated -There is significant soft-tissue swelling. These wound types respond well to negative pressure wound therapy. I do not use this image for shock and awe, but to demonstrate the recent injury types and the complexities associated with them. As you can see these are: -High AKA injuries with significant STI to perineal region requiring fecal diversion -They are heavily contaminated -There is significant soft-tissue swelling. These wound types respond well to negative pressure wound therapy.

41. Advancing The Science Negative Pressure Wound Therapy (NPWT) Increasing blood flow through reduction of interstitial edema Removal of inflammatory cytokines and management of exudate Mechanical deformation of cells Other benefits Reduces need for frequent changes Contains effluent Research Infection 41 NPWT is proposed to promote granulation tissue formation and increased wound healing through 4 actions: Increasing blood flow to the region through reduction of interstitial fluid at the wound site. Removal of inflammatory cytokines and management of wound effluent Mechanical deformation of cells or cell stretch Maintaining a warm moist environment Other benefits include: Reduced need for dressing changes Management of effluent and containment of fluid. This reduces infection risks and allows for researchers to collect wound effluent for research purposes. - NPWT allows for a systematic approach for wound management throughout the continuum�every 2-3 days wound debridement and washout, and VAC change. NPWT is proposed to promote granulation tissue formation and increased wound healing through 4 actions: Increasing blood flow to the region through reduction of interstitial fluid at the wound site. Removal of inflammatory cytokines and management of wound effluent Mechanical deformation of cells or cell stretch Maintaining a warm moist environment Other benefits include: Reduced need for dressing changes Management of effluent and containment of fluid. This reduces infection risks and allows for researchers to collect wound effluent for research purposes. - NPWT allows for a systematic approach for wound management throughout the continuum�every 2-3 days wound debridement and washout, and VAC change.

42. Advancing The Science Negative Pressure Wound Therapy (NPWT) 2008 in-flight feasibility study LRMC to CONUS 2009 Challenge; NPWT units available for in-flight care Air Force purchased units placing into PMI 2010 significant increase in MEDEVAC Wounded receiving NPWT 42 Members of the CWLS Program have been involved in the championing of NPWT for the management of Wounded throughout the continuum. We participated in the feasibility study with LRMC and COL Fang. We pushed to get Wound VACs in the PMI on MEDEVAC flights in order to allow for NPWT during transfer of Wounded from LRMC and CONUS. This action not only affected use during aero medical evacuation but facilitated initiation earlier at LRMC. Once Wound VACs were placed on-board MEDEVAC flights, usage increased significantly (1-2 one year ago, to 10-15 in fall of 2010) Members of the CWLS Program have been involved in the championing of NPWT for the management of Wounded throughout the continuum. We participated in the feasibility study with LRMC and COL Fang. We pushed to get Wound VACs in the PMI on MEDEVAC flights in order to allow for NPWT during transfer of Wounded from LRMC and CONUS. This action not only affected use during aero medical evacuation but facilitated initiation earlier at LRMC. Once Wound VACs were placed on-board MEDEVAC flights, usage increased significantly (1-2 one year ago, to 10-15 in fall of 2010)

43. Advancing The Science Developing solutions to complex problems Increasing incidence of high AKA amputations with accompanying fungal infections Need for local therapy Wound VAC� Instill� therapy Dakin�s irrigation solution Optimized Stabilized Hypochlorous Solution Decrease bacteria at all time points after initiation of treatment (p=0.0002) 43 We worked to develop solutions for the management of these high AKA injuries which often had accompanying fungal or MDRO. Initiated the VAC Instill therapy using a diluted Dakin�s solution. We were able to confirm the effectiveness of Dakin�s through work performed by Orthopaedic researchers who were identifying the best interventions for bacterial reduction using a fracture model.We worked to develop solutions for the management of these high AKA injuries which often had accompanying fungal or MDRO. Initiated the VAC Instill therapy using a diluted Dakin�s solution. We were able to confirm the effectiveness of Dakin�s through work performed by Orthopaedic researchers who were identifying the best interventions for bacterial reduction using a fracture model.

44. Bacteria Quantity In Open Fracture Model 44

45. Education / Knowledge Transfer Pressure ulcer prevention program Incidence of pressure ulcer formation among Wounded FMEA, chart review, EBP project 45 Another arm of our program is education. We provide education in best practice related to wound care. We also develop and implement procedures and processes, and therefore must develop and implement the educational programs accompanying them to ensure effective implementation. Furthermore, we work to establish electronic documentation flowcharting and templates to be used with the Essentris documentation system.Another arm of our program is education. We provide education in best practice related to wound care. We also develop and implement procedures and processes, and therefore must develop and implement the educational programs accompanying them to ensure effective implementation. Furthermore, we work to establish electronic documentation flowcharting and templates to be used with the Essentris documentation system.

46. Education / Knowledge Transfer 46 An example of our wound care education tool for the new integrated pressure ulcer prevention and management policy.An example of our wound care education tool for the new integrated pressure ulcer prevention and management policy.

47. Education / Knowledge Transfer 47 This bed algorithm not only provides education for the clinician on what beds are available to order and how to order, but it also reinforces prevention factors.This bed algorithm not only provides education for the clinician on what beds are available to order and how to order, but it also reinforces prevention factors.

48. Education / Knowledge Transfer 48 This list is a compilation from a survey we performed with deployed nurses, and an article written by COL Smith which identified critical competencies for the ICU nurse in an austere environment. This list is a compilation from a survey we performed with deployed nurses, and an article written by COL Smith which identified critical competencies for the ICU nurse in an austere environment.

49. Education / Knowledge Transfer DoD / VA Wound Care Course Established in 2008 Extensive 5-day course with skills training Open to DoD and VA Physicians, Nurses, Physical Therapists, Corpsmen/Medics Future WOCN approved course with credentials Emory University Wound Care Specialty Course Preceptor Program MOU with Emory at NNMC and WRAMC Military and civilian students From our survey, the list by COL Smith, and recognized educational needs regarding advanced wound care we developed a DoD wound care course. The course was initially designed for DoD personnel only; however, we opened to VA personnel to ensure representation of the entire continuum of care. We are working with the WOCN to strengthen and standardize the program ad hope to provide a program that will allow participants to leave with wound care credentials. In addition we have recently entered into a relationship with Emory university�s wound care program that would allow us to provide clinical experiences for wound care certified nurses. From our survey, the list by COL Smith, and recognized educational needs regarding advanced wound care we developed a DoD wound care course. The course was initially designed for DoD personnel only; however, we opened to VA personnel to ensure representation of the entire continuum of care. We are working with the WOCN to strengthen and standardize the program ad hope to provide a program that will allow participants to leave with wound care credentials. In addition we have recently entered into a relationship with Emory university�s wound care program that would allow us to provide clinical experiences for wound care certified nurses.

50. Education / Knowledge Transfer 50 As mentioned earlier, our wound care selection guide which serves as an educational tool.As mentioned earlier, our wound care selection guide which serves as an educational tool.

51. Education / Knowledge Transfer NNMC and WRAMC wound education programs and policy development NPWT Standard Instill� VAC� therapy Institutional wound care education Departmental training Orientation Policy education 51 We are involved in policy development and with that duty is the obligation to educate and train personnel in the new process. Most recently we implemented the VAC Instill program for care of our returning Wounded. This therapy has a potential for injury if used incorrectly. We had to obtain equipment, supplies, and educate the end users. KCI had no more than 2 in the area the supply line was not established. This was a relatively unused therapy. We had to review the evidence to determine best practice and safe practice. KCI looked to us for guidance. We are involved in policy development and with that duty is the obligation to educate and train personnel in the new process. Most recently we implemented the VAC Instill program for care of our returning Wounded. This therapy has a potential for injury if used incorrectly. We had to obtain equipment, supplies, and educate the end users. KCI had no more than 2 in the area the supply line was not established. This was a relatively unused therapy. We had to review the evidence to determine best practice and safe practice. KCI looked to us for guidance.

52. Business Operations Specialty bed and support surface management $1 million dollar + per year NNMC $450,000 in 2007 WRAMC $950,000 in 2009 Collaborative effort to establish WRNMMC contract and algorithm Enhance care Efficient operations 52 One frequently overlooked component for a wound care program is business operations and management. Like the clinical fragmentation we noted fragmented business operations that were causing inefficiencies related to workload and fiscal outlay. In 2007 NNMC was spending over $450,000/year on bed rentals. In addition we had an increasing incident of pressure ulcers. By analyzing the process, implementing new processes, and education end users on bed usage we reduced the incidences of pressure ulcers and reduced out costs to below $200,000 / year. At NNMC we are currently working on a new integrated bed and support surface contract and educational program for the upcoming year which will incorporate the integrated facility WRNMMC. One frequently overlooked component for a wound care program is business operations and management. Like the clinical fragmentation we noted fragmented business operations that were causing inefficiencies related to workload and fiscal outlay. In 2007 NNMC was spending over $450,000/year on bed rentals. In addition we had an increasing incident of pressure ulcers. By analyzing the process, implementing new processes, and education end users on bed usage we reduced the incidences of pressure ulcers and reduced out costs to below $200,000 / year. At NNMC we are currently working on a new integrated bed and support surface contract and educational program for the upcoming year which will incorporate the integrated facility WRNMMC.

53. Business Operations Wound VAC� / Negative Pressure Wound Therapy (NPWT) Over $2 million per year between NNMC / WRAMC Recent purchase of 20 units at NNMC $450,000 One year return on investment In-house tracking program to reduce waste 53 NPWT rentals and supply expenses are currently running in excess of $2 million dollars per year within the NCA. Identifying that we could use end of year funds to reduce our dependence on rental units we purchased 20 units at $450,000 dollars. If we use all units for one year we will save $500,000 in the first year. A Life cycle for one device is 7-10 years. We also implemented a tracking program for all VAC units, both rental and purchased units. This reduced inefficiencies costing in excess of $50,000 per year�if none are lost!NPWT rentals and supply expenses are currently running in excess of $2 million dollars per year within the NCA. Identifying that we could use end of year funds to reduce our dependence on rental units we purchased 20 units at $450,000 dollars. If we use all units for one year we will save $500,000 in the first year. A Life cycle for one device is 7-10 years. We also implemented a tracking program for all VAC units, both rental and purchased units. This reduced inefficiencies costing in excess of $50,000 per year�if none are lost!

54. Business Operations Wound care supplies Standardize throughout the NCA Establish product availability Future: mail order supplies Ostomy supply distribution Transfer to a mail-order process Reduce MTF expenditures for outpatient supplies Reduce storage space required Provide broader range products Convenient delivery 54 As mentioned we have standardized wound care supplies throughout the NCA reducing cost, reducing variances, and enhancing education. We have standardized ostomy supplies as well ad are working to implement a mail order system for WRAMC prior to integration. Currently NNMC has a mail order supply system in place. This process: reduces MTF expenditures and transfers that cost to TRICARE or MEDICARE reduces storage space necessary Provides the beneficiary with a much larger choice of products Supplies are delivered monthly to the beneficiaries' homeAs mentioned we have standardized wound care supplies throughout the NCA reducing cost, reducing variances, and enhancing education. We have standardized ostomy supplies as well ad are working to implement a mail order system for WRAMC prior to integration. Currently NNMC has a mail order supply system in place. This process: reduces MTF expenditures and transfers that cost to TRICARE or MEDICARE reduces storage space necessary Provides the beneficiary with a much larger choice of products Supplies are delivered monthly to the beneficiaries' home

55. DoD Level Activities Make advanced wound care supplies available to the operational end user Develop a standardized advanced wound care pictorial formulary and educational guide Evidence-based wound care practices Provide the user with all necessary ordering information NSN�s and Prime Vendor Numbers Provide all six possible product identifiers 55 Once we standardized the wound care supplies for the NCA we began to consider a similar process for the operational setting. Frequently deploying providers carry advanced wound care supplies with them on deployment and throughout their deployment they request supplies to be sent to them from colleagues back home. This is due in part to there being no advanced wound care AMAL/assemblage available, a lack of provider knowledge regarding available products, and unfamiliarity with ordering process. Our vision was to create an advanced wound care formulary containing supplies useful throughout the continuum of care, a pictorial user guide, and all necessary ordering information.Once we standardized the wound care supplies for the NCA we began to consider a similar process for the operational setting. Frequently deploying providers carry advanced wound care supplies with them on deployment and throughout their deployment they request supplies to be sent to them from colleagues back home. This is due in part to there being no advanced wound care AMAL/assemblage available, a lack of provider knowledge regarding available products, and unfamiliarity with ordering process. Our vision was to create an advanced wound care formulary containing supplies useful throughout the continuum of care, a pictorial user guide, and all necessary ordering information.

56. DoD Level Activities Established a Joint wound care advisory team Army, Navy, Air-Force, Marines, Canadian AF, civilian and military wound care experts, and DoD logisticians (DMMPO) Defined current advanced wound care needs for the operational environment Acute and chronic 56 A Joint wound care advisory team was established with members throughout all services who had been deployed, and or were experts in wound care of the Wounded. We also sought assistance from DMMPO to help us clarify the ordering process, and acquire all necessary product ordering information. There are 6 product identifiers available. A Joint wound care advisory team was established with members throughout all services who had been deployed, and or were experts in wound care of the Wounded. We also sought assistance from DMMPO to help us clarify the ordering process, and acquire all necessary product ordering information. There are 6 product identifiers available.

57. DoD Level Activities 57 This is an example of one of the pages from the Operational Formulary. It includes: -Dressing type Indications for use Advantages Disadvantage Products available within the category along with manufacturer and ordering information This is an example of one of the pages from the Operational Formulary. It includes: -Dressing type Indications for use Advantages Disadvantage Products available within the category along with manufacturer and ordering information

58. DoD Level Activities 58 On this page you will see the instructions for use, Images of the type of wounds you would use the product with, and reference information. On this page you will see the instructions for use, Images of the type of wounds you would use the product with, and reference information.

59. DoD Level Activities SME for advanced wound care NPWT standardization AMAL configuration AMAL for Advanced Wound Care 59 Our relationship with DMMPO has allowed us to work together on other projects such as NPWT standardization and assemblages, as well as AMAL configuration. Our relationship with DMMPO has allowed us to work together on other projects such as NPWT standardization and assemblages, as well as AMAL configuration.

60. Questions? CLINICAL: Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s EDUCATIONAL: Establish center of excellence for wound healing education through DoD/VA wound course Deployment wound care education Educational opportunities for nursing, house staff, and students Prevention of pressure ulcers in OIF/OEF and beneficiaries through joint policy development and education RESEARCH: Shift from �eminence-based� practice to �evidence-based� practice Advancing wound healing science for combat casualties and beneficiaries Reduced time to healing, rehabilitation, and RTD Improved wound-related pain and quality of life Reduced fiscal outlay through focused, resource utilization prudent treatment STANDARDIZATION: Standardized wound, ostomy, skin care product lines Availability and continuity of goods and services Reduction in costs Facilitate education and training Future: Standardize wound healing devices and modalities WRAMC, NNMC, WRNMMC, and throughout DoD CLINICAL: Significant increase in RVU production and prospective payment earnings Increased accessibility and specialty service to patients with complex wounds Decrease in purchased care for TRICARE PRIME enrollees Concept is transportable to other MTF�s EDUCATIONAL: Establish center of excellence for wound healing education through DoD/VA wound course Deployment wound care education Educational opportunities for nursing, house staff, and students Prevention of pressure ulcers in OIF/OEF and beneficiaries through joint policy development and education RESEARCH: Shift from �eminence-based� practice to �evidence-based� practice Advancing wound healing science for combat casualties and beneficiaries Reduced time to healing, rehabilitation, and RTD Improved wound-related pain and quality of life Reduced fiscal outlay through focused, resource utilization prudent treatment STANDARDIZATION: Standardized wound, ostomy, skin care product lines Availability and continuity of goods and services Reduction in costs Facilitate education and training Future: Standardize wound healing devices and modalities WRAMC, NNMC, WRNMMC, and throughout DoD