Selected Podcast
Pediatric Acute Wound Services (PAWS)
Brad Warner, MD, surgeon-in-chief at St. Louis Children's Hospital and division director of pediatric surgery at Washington University School of Medicine, is here to discuss The Pediatric Acute Wound Service Program (PAWS) at St. Louis Children’s Hospital. He also shares how it offers a program where staff specially trained in burn and wound care provide care to children in the hospital and to outpatients.
Featured Speaker:
Learn more about Brad Warner, MD
Brad Warner, MD
Brad Warner, MD, Washington University pediatric general surgeon and surgeon-in-chief at St. Louis Children’s Hospital. He has a special interest in pediatric gastroenterology and nutrition including short bowel syndrome and inflammatory bowel disease.Learn more about Brad Warner, MD
Transcription:
Melanie Cole (Host): Our topic today is the Pediatric Acute Wound Services Program or PAWS at St. Louis Children’s Hospital. My guest is Dr. Brad Warner. He is the surgeon and chief at St. Louis Children’s Hospital and division director of pediatric surgery at Washington University School of Medicine. So, Dr. Warner, explain a little bit about PAWS at St. Louis Children’s. What’s the evolution of it?
Brad Warner, MD (Guest): Well this actually I think is a very, very unique program that began probably I would say maybe 15 years ago and I think it arose as an alternative and I think an efficient way of caring for the many children that we see with infections, abscesses, minor wounds, things like dressing changes that are uncomfortable and typically, we would have to take these children to the operating room, they get general anesthesia and these are very frequent cases. They are a short duration and really could tie up a lot of time in the operating room and delay for children to get taken care of during the day. So, ultimately, this service developed to manage acute wound care and began staffed by pediatric nurse practitioners that have all undergone training in wound care and wound management and actually then got some real estate on the tenth floor of our Children’s Hospital which is on our surgical floor to be able to see not only inpatients with acute wound problems but outpatients as well. So, it’s evolved. It offloads the operating room. It’s a much more intimate environment where people are very focused on wound care and sedation and avoidance of pain for the children. So, it’s a very, very efficient way of dealing with some of these problems.
Melanie: Well isn’t that the most important thing really to keep the children out of pain as much as possible when they are suffering from some of these wounds. Tell us what kinds of conditions are you talking about? Are we talking about burns, and things that might happen as a result of surgery, what are you dealing with?
Dr. Warner: Virtually everything you have mentioned. So, probably one of the most common things that we see is abscesses. Abscesses on the skin, there can be pilonidal abscesses on the back side. These can actually work out well because children come to the emergency room with an abscess or they are seen by their private pediatrician with an abscess and rather than go through an incision and drainage which can be quite painful; injecting local and then cutting it with a knife and everything and you can imagine with a child that’s quite scary. So, what we can do at PAWS is make an appointment, let our PAWS nurses know that the child has an abscess, they can start them on antibiotics on their way to the hospital and they are seen, and they can have their abscess drained with conscious sedation that’s provided by our hospitalist here at St. Louis Children’s Hospital. So, they are asleep, they don’t know what’s going on, they wake up and it’s done. I think the nice thing about it is we can do this for children that have an abscess that is newly discovered, but if they have not been NPO, in other words if they have just eaten or something like that, then the risk for sedation is higher. So, we would actually just go ahead and start them on some antibiotics and then make a scheduled appointment for them to come in the next morning at PAWS and have their drainage done. So, I think that’s a much kinder, gentler way of dealing with something that can be quite painful and a traumatic experience for the child.
But in terms of other things, we do burn wound dressing changes. Those can be quite painful. The dressing can stay on usually for a couple of days, but then they can come in to have their dressings changed, have their wounds scrubbed down and reassessed for how they are healing and then redressed, all under sedation. We have a smattering of things that would initiate pain in a child that we try to avoid such as splinter removal, removing toenails that are ingrown, sometimes if there’s drains or chest tubes and things that need to be pulled, we can do that with conscious sedation. Anything that really is perceived of as relating to surgery that is perceived of as being uncomfortable or potentially difficult for the child to go through, that’s when we can initiate the PAWS program. And they do transport, so most of the time we bring our patients to the PAWS unit, but a lot of our PAWS nurses are seen throughout the hospital. They go to the pediatric intensive care unit where patients will get sedation by the intensivists and the PAWS wound care nurses will go by and assess the wounds and make appropriate recommendations for therapy. So, they go throughout the hospital. They are seen on the regular floors as well as the intensive care units and on our oncology floors and they are available throughout the hospital for consultation as well if a child is developing a pressure sore or develops a wound that is difficult to manage on the floor, they get consulted and they go and deal with it.
Melanie: And you mentioned that some of the staff include nurse practitioners and that they are specially certified, speak about the certifications and credentials of the staff at PAWS.
Dr. Warner: So, it is primarily run by nurse practitioners that have received special training after their RN degree to go on and get a pediatric nurse practitioner degree. After that, then they do a specialized wound care certification course and I think that’s both didactic as well as practical. They have to take an exam for that. There are very few of those around our region, but everyone that is working independently at PAWS has that degree. Now there are always – we have a collaborative practice arrangement with faculty, pediatric surgeons here at St. Louis Children’s for each one of them so, with the proximity of the PAWS unit to our offices and to the operating rooms and certainly within the hospital; we always have faculty available to come up and look at things that they are uncomfortable with and to be involved if there is any certain questions or anything like that. So, it’s very collaborative. The nice thing is they know that when we are on the floor making rounds and they know when they have got certain patients scheduled and when we will be there and it’s a lot of great communication of the patient’s going to be asleep in ten minutes are you available? And you just text back and say I’ll be up. Or I’m not available, when can you go, let’s do it at this time. And so, it’s sort of like a controlled command center if you will, to coordinate when physicians can be available with their schedule, with the patient’s schedule and they just make it happen so efficiently.
Melanie: Well you pretty much answered the next question about the move. So, you recently moved. So, explain a little bit, I mean you just gave us some of those amazing benefits of that move. How did that come about?
Dr. Warner: Well the – actually we have been on the tenth floor for ten years or 15 years. We recently moved to our ambulatory procedure center and that has more rooms. It is integrated with a lot of the other things that were not being done in PAWS such as sedation for other procedures and that type of thing. So, it brings greater real estate space really. It’s on the first floor rather than the tenth floor, but I think the advantages are that we have anesthesia providing much of the sedation now as opposed to the hospitalists and that actually opens the door for different types of medications that might be better for certain children. So, I think it expands our capacity for doing more complex children certainly with the anesthesiologists.
Melanie: Dr. Warner, how does PAWS decrease patient admissions, cost for care, give us some of the other program highlights.
Dr. Warner: Well I think it really makes a big difference, because if you have a child say shows up in the emergency room at 8 or 9 o’clock at night which is very frequent. Parents get home from work, they notice something abnormal, they have dinner and then come to the emergency room and if they could be seen in the emergency room and identified as having an abscess that needs to be drained; that’s a pretty straightforward we will put you on some antibiotics, don’t feed your child past midnight, here’s the number for PAWS and they call in the next morning and they have a time to come in and have that abscess drained. Without PAWS, they would likely be admitted to the hospital, spend the night in the hospital unnecessarily and then go home after their procedure has been done. So, it does prevent admissions. It also because we can see patients rather quickly, and deal with the conditions, it gets them out of the hospital sooner. So, sometimes in other circumstances, I would say without PAWS, patients might be seen, admitted, they might wait quite a while for their drainage to be done and then because it’s late in the day, they might have to stay another day. With PAWS and being able to jump on things early in the morning and get it addressed, many of these kids can go home same day or certainly very early the next day which saves on hospital days.
Melanie: What about the parents Dr. Warner. How are they involved in PAWS and what are you hearing from them about the way that this program works and the ability of the physicians and clinicians to be able to get to the children quickly and be all in a similar area? What are you hearing from parents?
Dr. Warner: We hear it’s wildly successful and popular. I think parents love it. Actually, you know our nurses are so committed in what they do that we have developed, or I have been made aware of relationships with parents that are just really incredible. Particularly children with chronic wound conditions where it’s not just a simple incision and drainage, but it’s managing a big open wound that may take weeks to months to close and that they can come in and have someone to talk to specifically focused on the wound, they take pictures, they show the families the progression of healing and I think the relationships that they develop are really outstanding. Our lead nurse practitioner Jen Seagal who has run PAWS for quite a while, won the nurse of the year award in St. Louis Magazine based on a tremendous letter that she received thanking her from a very, very grateful patient with a very severe wound problem and Jen really sort of made it her private patient to make sure wherever this kid was in the hospital system, whether it be in the emergency room, going to the operating room, on another floor would always go by and make sure about the wounds and touch base with the nurses and care providers to make sure it was done correctly and that type of continuity is hard to find. And I think that the fact that she won that award, it’s been a while now, but we get those letters all the time.
Melanie: Isn’t that amazing? So, what are some of your goals going forward and wrap it up for us. Tell other physicians what you’d like them to know about the Pediatric Acute Wound Service at St. Louis Children’s Hospital and your goals going forward.
Dr. Warner: Well I think our goals are to provide the best, most efficient and evidence-based care for our children. So, children with abscesses, children with any sort of thing that needs attention from a surgical standpoint should give our PAWS unit a call. We are available pretty much seven days a week to deal with issues that develop, and it really can be facilitated through your office by calling them. They will come up with a plan for you and really take it from there. We want to provide the best service to our pediatricians that are referring, and we want families to be able to go home happy. Our goals really, I think are to become more – to generate more clinical trials and things testing various products in the market for wound management. We are always pushing the envelope for different types of wound type procedures and wound care and to continue doing that and write our experience up and publish that. We have published several manuscripts already about our wound clinic and the PAWS program and I think that’s something that we want to continue to do. And we certainly want to expand our coverage and let the pediatricians know that we are there to help them.
Melanie: That’s perfect. Thank you so much Dr. Warner for being with us today and telling us about PAWS. A physician can refer a patient by calling Children’s direct physician access line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for tuning in.
Melanie Cole (Host): Our topic today is the Pediatric Acute Wound Services Program or PAWS at St. Louis Children’s Hospital. My guest is Dr. Brad Warner. He is the surgeon and chief at St. Louis Children’s Hospital and division director of pediatric surgery at Washington University School of Medicine. So, Dr. Warner, explain a little bit about PAWS at St. Louis Children’s. What’s the evolution of it?
Brad Warner, MD (Guest): Well this actually I think is a very, very unique program that began probably I would say maybe 15 years ago and I think it arose as an alternative and I think an efficient way of caring for the many children that we see with infections, abscesses, minor wounds, things like dressing changes that are uncomfortable and typically, we would have to take these children to the operating room, they get general anesthesia and these are very frequent cases. They are a short duration and really could tie up a lot of time in the operating room and delay for children to get taken care of during the day. So, ultimately, this service developed to manage acute wound care and began staffed by pediatric nurse practitioners that have all undergone training in wound care and wound management and actually then got some real estate on the tenth floor of our Children’s Hospital which is on our surgical floor to be able to see not only inpatients with acute wound problems but outpatients as well. So, it’s evolved. It offloads the operating room. It’s a much more intimate environment where people are very focused on wound care and sedation and avoidance of pain for the children. So, it’s a very, very efficient way of dealing with some of these problems.
Melanie: Well isn’t that the most important thing really to keep the children out of pain as much as possible when they are suffering from some of these wounds. Tell us what kinds of conditions are you talking about? Are we talking about burns, and things that might happen as a result of surgery, what are you dealing with?
Dr. Warner: Virtually everything you have mentioned. So, probably one of the most common things that we see is abscesses. Abscesses on the skin, there can be pilonidal abscesses on the back side. These can actually work out well because children come to the emergency room with an abscess or they are seen by their private pediatrician with an abscess and rather than go through an incision and drainage which can be quite painful; injecting local and then cutting it with a knife and everything and you can imagine with a child that’s quite scary. So, what we can do at PAWS is make an appointment, let our PAWS nurses know that the child has an abscess, they can start them on antibiotics on their way to the hospital and they are seen, and they can have their abscess drained with conscious sedation that’s provided by our hospitalist here at St. Louis Children’s Hospital. So, they are asleep, they don’t know what’s going on, they wake up and it’s done. I think the nice thing about it is we can do this for children that have an abscess that is newly discovered, but if they have not been NPO, in other words if they have just eaten or something like that, then the risk for sedation is higher. So, we would actually just go ahead and start them on some antibiotics and then make a scheduled appointment for them to come in the next morning at PAWS and have their drainage done. So, I think that’s a much kinder, gentler way of dealing with something that can be quite painful and a traumatic experience for the child.
But in terms of other things, we do burn wound dressing changes. Those can be quite painful. The dressing can stay on usually for a couple of days, but then they can come in to have their dressings changed, have their wounds scrubbed down and reassessed for how they are healing and then redressed, all under sedation. We have a smattering of things that would initiate pain in a child that we try to avoid such as splinter removal, removing toenails that are ingrown, sometimes if there’s drains or chest tubes and things that need to be pulled, we can do that with conscious sedation. Anything that really is perceived of as relating to surgery that is perceived of as being uncomfortable or potentially difficult for the child to go through, that’s when we can initiate the PAWS program. And they do transport, so most of the time we bring our patients to the PAWS unit, but a lot of our PAWS nurses are seen throughout the hospital. They go to the pediatric intensive care unit where patients will get sedation by the intensivists and the PAWS wound care nurses will go by and assess the wounds and make appropriate recommendations for therapy. So, they go throughout the hospital. They are seen on the regular floors as well as the intensive care units and on our oncology floors and they are available throughout the hospital for consultation as well if a child is developing a pressure sore or develops a wound that is difficult to manage on the floor, they get consulted and they go and deal with it.
Melanie: And you mentioned that some of the staff include nurse practitioners and that they are specially certified, speak about the certifications and credentials of the staff at PAWS.
Dr. Warner: So, it is primarily run by nurse practitioners that have received special training after their RN degree to go on and get a pediatric nurse practitioner degree. After that, then they do a specialized wound care certification course and I think that’s both didactic as well as practical. They have to take an exam for that. There are very few of those around our region, but everyone that is working independently at PAWS has that degree. Now there are always – we have a collaborative practice arrangement with faculty, pediatric surgeons here at St. Louis Children’s for each one of them so, with the proximity of the PAWS unit to our offices and to the operating rooms and certainly within the hospital; we always have faculty available to come up and look at things that they are uncomfortable with and to be involved if there is any certain questions or anything like that. So, it’s very collaborative. The nice thing is they know that when we are on the floor making rounds and they know when they have got certain patients scheduled and when we will be there and it’s a lot of great communication of the patient’s going to be asleep in ten minutes are you available? And you just text back and say I’ll be up. Or I’m not available, when can you go, let’s do it at this time. And so, it’s sort of like a controlled command center if you will, to coordinate when physicians can be available with their schedule, with the patient’s schedule and they just make it happen so efficiently.
Melanie: Well you pretty much answered the next question about the move. So, you recently moved. So, explain a little bit, I mean you just gave us some of those amazing benefits of that move. How did that come about?
Dr. Warner: Well the – actually we have been on the tenth floor for ten years or 15 years. We recently moved to our ambulatory procedure center and that has more rooms. It is integrated with a lot of the other things that were not being done in PAWS such as sedation for other procedures and that type of thing. So, it brings greater real estate space really. It’s on the first floor rather than the tenth floor, but I think the advantages are that we have anesthesia providing much of the sedation now as opposed to the hospitalists and that actually opens the door for different types of medications that might be better for certain children. So, I think it expands our capacity for doing more complex children certainly with the anesthesiologists.
Melanie: Dr. Warner, how does PAWS decrease patient admissions, cost for care, give us some of the other program highlights.
Dr. Warner: Well I think it really makes a big difference, because if you have a child say shows up in the emergency room at 8 or 9 o’clock at night which is very frequent. Parents get home from work, they notice something abnormal, they have dinner and then come to the emergency room and if they could be seen in the emergency room and identified as having an abscess that needs to be drained; that’s a pretty straightforward we will put you on some antibiotics, don’t feed your child past midnight, here’s the number for PAWS and they call in the next morning and they have a time to come in and have that abscess drained. Without PAWS, they would likely be admitted to the hospital, spend the night in the hospital unnecessarily and then go home after their procedure has been done. So, it does prevent admissions. It also because we can see patients rather quickly, and deal with the conditions, it gets them out of the hospital sooner. So, sometimes in other circumstances, I would say without PAWS, patients might be seen, admitted, they might wait quite a while for their drainage to be done and then because it’s late in the day, they might have to stay another day. With PAWS and being able to jump on things early in the morning and get it addressed, many of these kids can go home same day or certainly very early the next day which saves on hospital days.
Melanie: What about the parents Dr. Warner. How are they involved in PAWS and what are you hearing from them about the way that this program works and the ability of the physicians and clinicians to be able to get to the children quickly and be all in a similar area? What are you hearing from parents?
Dr. Warner: We hear it’s wildly successful and popular. I think parents love it. Actually, you know our nurses are so committed in what they do that we have developed, or I have been made aware of relationships with parents that are just really incredible. Particularly children with chronic wound conditions where it’s not just a simple incision and drainage, but it’s managing a big open wound that may take weeks to months to close and that they can come in and have someone to talk to specifically focused on the wound, they take pictures, they show the families the progression of healing and I think the relationships that they develop are really outstanding. Our lead nurse practitioner Jen Seagal who has run PAWS for quite a while, won the nurse of the year award in St. Louis Magazine based on a tremendous letter that she received thanking her from a very, very grateful patient with a very severe wound problem and Jen really sort of made it her private patient to make sure wherever this kid was in the hospital system, whether it be in the emergency room, going to the operating room, on another floor would always go by and make sure about the wounds and touch base with the nurses and care providers to make sure it was done correctly and that type of continuity is hard to find. And I think that the fact that she won that award, it’s been a while now, but we get those letters all the time.
Melanie: Isn’t that amazing? So, what are some of your goals going forward and wrap it up for us. Tell other physicians what you’d like them to know about the Pediatric Acute Wound Service at St. Louis Children’s Hospital and your goals going forward.
Dr. Warner: Well I think our goals are to provide the best, most efficient and evidence-based care for our children. So, children with abscesses, children with any sort of thing that needs attention from a surgical standpoint should give our PAWS unit a call. We are available pretty much seven days a week to deal with issues that develop, and it really can be facilitated through your office by calling them. They will come up with a plan for you and really take it from there. We want to provide the best service to our pediatricians that are referring, and we want families to be able to go home happy. Our goals really, I think are to become more – to generate more clinical trials and things testing various products in the market for wound management. We are always pushing the envelope for different types of wound type procedures and wound care and to continue doing that and write our experience up and publish that. We have published several manuscripts already about our wound clinic and the PAWS program and I think that’s something that we want to continue to do. And we certainly want to expand our coverage and let the pediatricians know that we are there to help them.
Melanie: That’s perfect. Thank you so much Dr. Warner for being with us today and telling us about PAWS. A physician can refer a patient by calling Children’s direct physician access line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org , that’s www.stlouischildrens.org . This is Melanie Cole. Thanks so much for tuning in.