Written by Kymberlie McNicholas, Founder of The Way to My Heart

“The success of this model is more about availability and close communication between practices and the providers,” explains Vascular Institute’s Vascular Interventional Radiologist Mehrzad Zarghouni. “I can identify a CLTI patient and get them in to be seen for wound care the same day. Developing this partnership for the patient’s care is critical to being able to work quickly to save their limb.”

As part of our ongoing Vascular Innovation Series in conjunction with The Way to My Heart, Emmy Award-winning Journalist Kym McNicholas interviews Vascular Institute’s Vascular Interventional Radiologist, Mehrzad Zarghouni, and Advanced Wound Institute’s Wound Care Certified Nurse Practitioner, Kelsey Resler, about how their team has successfully implemented the Toe and Flow model to save life and limb in an office-based setting. This is part of an ongoing series focusing on the Toe and Flow model as it continues to scale around the world. In Part I, USC Keck School of Medicine Professor of Surgery and American Limb Preservation Society President Dr. David Armstrong discusses the origination of this model, its implementation, and challenges in scaling around the world. In Part II, Dr. Alex Reyzelman briefly describes the importance of the Toe & Flow Model to UCSF’s Center for Limb Preservation and the patients it serves.

Part I: Limb Saving Toe and Flow Model | Dr. David Armstronghttps://youtu.be/dX86Mjrazhc 

Part II: Limb Saving Toe and Flow Model | Dr. Alex Reyzelmanhttps://youtu.be/Zg3pwNNu_-A 

Danny had an ulcer on his right big toe that wouldn’t heal. His other foot, which had three toes removed, was a daily reminder of what would happen if it didn’t.  He was willing to do anything to save this toe. But, after his office-based vascular specialist restored flow to the foot, Danny couldn’t get an appointment within the 24-48 hours needed to see his wound care specialist for critical debridement of the wound. The nurse told him the doctor was on vacation and that he could see Danny in three weeks. Danny trusted the advice and continued to care for the wound at home. Unfortunately, the wound continued to get so inflamed that, during the two-week vascular follow-up, his doctor sent him immediately to the hospital for IV antibiotics with an urgent referral to another podiatrist. His toe was saved and has since healed. Danny was one of the lucky ones, but not everyone is as fortunate. Independent practices often struggle to coordinate around a specific timeline or care practice without a formal synergistic relationship.  

Studies show a multidisciplinary approach to treating diabetic foot ulcers leads to better patient outcomes. That approach includes a highly trained vascular specialist to restore flow to the small vessels below-the-ankle and a wound care specialist to ensure increase perfusion to the tissue surrounding the wound and debride the wound in a timely manner. It’s an approach that requires a highly responsive and synergistic relationship. Large hospital systems such as the University of Southern California’s Keck School of Medicine and UCSF’s Center for Limb Preservation have proven the model successful under one roof. Office-based labs (OBLs) are now appreciating that a single disciplinary approach to treating patients with non-healing ulcers isn’t always effective, especially if neighboring wound care clinics don’t available appointments when needed. Even so, patients often struggle to make those appointments even when they are available.  In response, more and more OBLs are hiring wound care specialists to join their teams. Modern Vascular, a chain of more than a dozen OBLs in America is officially launching its Toe and Flow model in June. Another chain of OBLs, Vascular Institute has its Toe and Flow model already operational through their relationships with partnered wound care centers, including Advanced Wound Institute. Vascular Institute’s Vascular Interventional Radiologist Mehrzad Zarghouni and Advanced Wound Institute’s Wound Care Certified Nurse Practitioner Kelsey Resler discuss the value of the Toe and Flow model in an OBL setting and the success they’ve had in using it to improve patient outcomes.  

How is Vascular Institute coordinating a consistent treatment process between vascular specialists and wound care specialists to align with what some academics call the ‘toe and flow’ model?  

Dr. Zarghouni: Vascular Institute has formed key relationships with wound care providers who share our vision for a comprehensive approach to patient care and treatment. Advanced Wound Institute is a great example of that. We do a lot of work together, healing our patients from the inside-out, and outside-in. We’ve been able to prevent countless amputations by working closely, and quickly, together.  

NP Resler: And if I can add to that, from the wound care perspective…many times I see very critical wounds that need immediate vascular attention. Having a trusted partner in Vascular Institute has helped seal that gap in care and allowed for my patients to be treated very quickly: restoring the blood flow so that my wound care can result in quicker and more effective healing. 

Does the toe & flow model need to take place under one roof? 

Dr. Zarghouni: It definitely can! But it doesn’t always need to. The success of this model is more about availability and close communication between practices and providers. I can identify a CLTI patient and get them in to be seen for wound care the same day. Developing this partnership for the patient’s care is critical to being able to work quickly to save their limb. 

Previously the toe & flow model has only been done in large hospital networks or medical schools. What value does making this model available in an office-based setting bring to patients?  

NP Resler: Patients appreciate being able to get exceptional prompt care without having to step foot inside of a hospital. We saw that especially over the last year and a half from the Covid-19 pandemic. Patients do not want to go to the hospital, and in most cases, they don’t need to! I think patients are starting to see that more and more treatment can be done safely in an outpatient office-based setting. Not to mention it’s typically much more affordable as well! 

What patient feedback has Vascular Institute received since implementing this model, and how has it impacted both heal rates and successful revascularizations?  

NP Resler: What I’ve seen is that patients really love the convenience. It simplifies their care plan, which is really refreshing for them since typically the patients we see with this pathology have 10+ different providers they are juggling. It can get overwhelming when you don’t have specialists come together.  

Dr. Zarghouni: In a clinical sense, there’s tremendous value in being able to care for the patient from the inside-out, and outside-in all within the span of a few hours. Before this model was implemented, vascular would send a referral to wound, or wound would send a referral to vascular. In most cases, just that referral process alone can take a few days to a few weeks for patients to get in and seen by each provider. When you have strong relationships with a partnered care team, that timeline is reduced significantly! In many cases, we can have our patient seen for vascular and wound care in the same day. When you are dealing with extremely critical patients like we typically are, every day and hour counts! We have been able to save many limbs by utilizing this comprehensive approach.  

Are you facing resistance in scaling this model, specifically in an office-based setting?  

Dr. Zarghouni: It’s interesting…I think some providers are very comfortable with how medicine has been done for the last 30+ years. Sometimes it’s easy to get stuck in a routine and not look for more efficient practices. So, with that, yes, we sometimes see resistance; however, I believe more and more forward-thinking physicians are coming into practice and we have seen stronger support of our model because of this. They prefer to lean on trusted local providers like us, who they know they can trust and work in conjunction with on their patients’ care. 

Does Vascular Institute have a plan to scale this model nationally?  

Dr. Zarghouni: Absolutely! We’ve received such amazing feedback from patients. And the number of limbs (& lives) we’ve been able to save because of this model has been incredible! Our goal is to be able to offer this level of care to patients all across the US. 


This interview was produced by The Way To My Heart in partnership with Vascular Cures. Neither The Way To My Heart nor Vascular Cures endorse any specific products, entrepreneurs, companies, organizations, drug or device trials, and/or healthcare professionals, including diagnosis or treatment programs. The information, advice, and views shared in this interview are that of the individual speakers and are offered for educational and informational purposes only.

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