Professor Zena Moore, from the European Wound Management Association (EWMA) identifies the benefits of wound care teams for patients and healthcare professionals
From a wound care perspective, the growing prevalence and incidence of non-healing acute and chronic wounds is a worrying concern. Indeed, the incidence of wounds in the EU-27 is approximately 4 million, and furthermore 2 million patients acquire hospital-acquired infections each year.1 It is estimated that more than 23% of all hospital in-patients have a pressure ulcer and most pressure ulcers occur during hospitalisation for an acute episode of illness/injury.2 The cost of just one problematic wound is between €6.650-10.000 per patient and the total cost of wound care accounts for 2-4 % of European health care budgets. Further, 27-50% of acute hospital beds are likely to be occupied on any day by patients with a wound.3
One of the biggest challenges in wound care is the lack of united services aimed at addressing all the health care needs of individuals with wounds.4 The WHO argues that professionals who actively bring the skills of different individuals together, with the aim of clearly addressing the health care needs of patients and the community, will strengthen the health systems and lead to enhanced clinical and health-related outcomes.5
However, despite some evidence 6 7, 8 the use of focussed interdisciplinary wound care teams is lacking within the literature, with disparity existing as to what exactly the term “interdisciplinary” means, and who exactly is eligible to be a member of this care team.9
The overarching objective of this project was to provide recommendations for implementing a team approach to wound care within all clinical settings and through this to develop a model for advocating the team approach toward decision-makers in national government levels.
What we found
A review and analysis of 18 years of literature related to managing wounds as a team reveals a consistently increasing evidence to support a team approach. When analysed according to wound types, literature related to diabetic foot ulcers comprises the largest body of knowledge, with many retrospectives and prospective reviews of long term programs, all demonstrating a positive team effect. Outcomes related to leg ulcer team care is supported by the highest quality of evidence. Pressure ulcer team benefits are mostly supported by descriptive reports of program outcomes. The team effect on chronic wound care is supported by a systematic review with emerging additional literature describing the positive effects of care delivered by teams in dedicated wound centres.
Outcome measures for all wound types are generally related to wound healing and amputation rates with some additional qualitative, quantitative and patient-centred endpoints. All outcomes have been reported positively, with no reports of negative consequences of a team intervention. Furthermore, the use of a team approach has been demonstrated in all healthcare settings across the continuum. Overall, study populations have been representative of the wound population at large. In addition, methodological issues are reflective of the research limitations and challenges in wound research as an aggregate.
Additional research is needed to clearly demonstrate the effect of the team approach to wound healing, particularly relating to financial and clinical outcomes, owing to the current challenges regarding reduced health budgets. Patient sensitive outcome measures should also be investigated with a specific focus on patient safety. Finally, exploration of the inter-professional educational opportunities in wound care will help differentiate the skill set required to maximise team function.
Universal Model for the Team Approach to Wound Care 10
It is obvious that a ‘one model fits all’ approach to building a team for the provision of wound care is unrealistic. Available resources, access to relevant expertise, remuneration provisions and patient populations will always be context-specific. It is evident however that the inclusion of key elements within wound care services will foster collaborations between different health care professionals and keep the needs of the patient at the forefront. The elements are depicted in Figure 3 and described below. The patient forms the focus of the care but relies on the expertise of a wound navigator to organise wound care service via established referral mechanisms. The wound navigator and other health professionals either collaborate to explore beneficial remuneration and health care systems and/or lobby to meet the needs of the patient.
In summary, we believe that effective management of wounds as a team requires the development of 5 essential elements:
- A patient focus using an advocate • for the patient – wound navigator;
- Referral mechanisms that are responsive;
- Aggregation of assessment data to form a single plan appropriate remuneration systems;
- A health care system is sensitive to team models.
Each element can be realised either via health care system reform or local collaboration. It has been suggested that clinicians interested in establishing wound team services begin at the local level by assuming the role of wound navigator. Interested clinicians could generate a list of local services, collaborate with identified services to develop referral mechanisms, aggregate assessment data collected by the services into to a care plan, explore options for better utilisation of existing remuneration schemes to fund the identified patients need, and collect data that supports the benefits of the wound team approach highlighted in the literature. Over time the local initiatives suggested have the potential to grow into a ‘groundswell’ of evidence that can be used to lobby government to instigate needed health care reform.
We advocate that the patient should be at the heart of all decision-making, as working with the Universal Model for the Team Approach to Wound Care, which begins with the needs of the patient. To facilitate this, we suggest the use of a wound navigator who acts as an advocate for the patient.
For more guidance on how to adopt this approach please refer to the original Position Document: Managing Wounds As a Team which can be downloaded via www.EWMA.org using this link:
1 Moore, Z., The war on wounds. Public Sector review: Europe, 2012.24: p. 1-2.
2 European Pressure Ulcer Advisory Panel, Summary report on the prevalence of pressure ulcers. EPUAP Review, 2002. 4(2): p. 49-57.
3 Posnett, J., et al., The resource impact of wounds on health-care providers in Europe. Journal of Wound Care, 2009. 18(4): p. 154-61.
4 Lazzarini, P., et al., Diabetes foot disease: the Cinderella of Australian diabetes management? J Foot Ankle Res, 2012. 5(1): p. 24.
5 World Health Organisation, Framework for action on interprofessional education & collaborative practice, Department of Human Resources for Health, Editor. 2010, World Health Organisation Geneva.
6 Lindholm, C., A. Bergsten, and E. Berglund, Chronic Wounds and Nursing Care. Journal of Wound Care, 1999. 8(1): p. 5-10.
7 Patout, C., et al., Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care, 2000. 23(9): p. 1339-42.
8 Dargis, V., et al., Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. Diabetes Care, 1999. 22(9): p. 1428-31.
9 Vu, T., et al., Cost-effectiveness of multidisciplinary wound care in nursing homes: a pseudo-randomized pragmatic cluster trial. Family Practice, 2007. 24: p. 372-9.
10 Moore, Z., et al., Exploring the concept of a team approach to wound care: Managing Wounds As a Team. J Wound Care, 2014. 23 Suppl 5b: p. S1-S38.
This article is based on the Position Document Managing Wounds as A Team initiated by the Association for the Advancement of Wound Care (AAWC-USA), the Australian Wound Management Association (AWMA) and the European Wound Management Association (EWMA) and realised in collaboration with The International Working Group on the Diabetic Foot (IWGDF). The overall aim of this Position Document was to provide a universal model for the adoption of a team approach to wound care.
Professor Zena Moore PhD
Head of School of Nursing & Midwifery – Royal College of Surgeons in Dublin, Ireland
Past President – European Wound Management Association (EWMA)