Managing Wounds As A Team: Exploring The Concept of A Team Approach To Wound Care

Exploring the
concept of a
team approach
to wound care
MANAGING
WOUNDS
AS A TEAM
A joint position document
AAWC
Zena Moore,1 (Editor) PhD, MSc, FFNMRCSI, PG Dip, Dip Management, RGN, Professor, Head of School, Chair of the
document Author Group; Former President, European Wound Management Association,
Gillian Butcher,2 B App Sc (Pod), Adv Dip Bus Mgmt, Senior Podiatry Manager; Australian Wound Management Association,
Lisa Q. Corbett,3 MSN, APRN, DNPc, CWOCN, Nurse Practitioner Wound Care; Association for the Advancement of
Wound Care,
William McGuiness,4 PhD, MSN, Associate Professor; Australian Wound Management Association,
Robert J. Snyder,5 DPM, MSc, CWS Professor and Director of Clinical Research; President, Association for the Advancement
of Wound Care,
Kristien van Acker,6 Md , PhD Diabetologist; European Wound Management Association, Chair International Working
Group on the Diabetic Foot, Chair Consultative Section Diabetic Foot of the International Diabetes Federation (IDF)
1 School of Nursing & Midwifery, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland;
2 Monash Health, 246 Clayton Rd, Clayton VIC 3168, Australia;
3 Hartford HealthCare, Hartford CT and Yale University School of Nursing, New Haven, CT, USA;
4 La Trobe University, Alfred Health Clinical School, Level 4, The Alfred Centre, 99 Commercial Road, Prahran VIC 3181,
Australia;
5 Barry University, 11300 NE 2nd Avenue, Miami Shores, FL 33161, USA;
6 Hospital H Familie, Rumst and Centre de Santé des Fagnes- Chimay, Belgium.
Editorial support and coordination: EWMA Secretariat
Corresponding author: Editor, Professor Zena Moore [email protected]

The document is supported by an unrestricted grant from BSN Medical, Flen Pharma, KCI, Lohmann & Rauscher and Nutricia.
This article has not undergone double-blind peer review;

This article should be referenced as: Moore, Z., Butcher, G., Corbett, L. Q., et al. AAWC, AWMA, EWMA Position Paper:
Managing Wounds as a Team. J Wound Care 2014; 23 (5 Suppl.): S1–S38.
© EWMA 2014
All rights reserved. No reproduction, transmission or copying of this publication is allowed without written
permission. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or
by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission
of the European Wound Management Association (EWMA) or in accordance with the relevant copyright legislation.
Although the editor, MA Healthcare Ltd. and EWMA have taken great care to ensure accuracy, neither
MA Healthcare Ltd. nor EWMA will be liable for any errors of omission or inaccuracies in this publication.
Published on behalf of EWMA by MA Healthcare Ltd.

Publisher: Anthony Kerr
Editor: Karina Huynh
Designer: Milly McCulloch
Published by: MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London, SE24 0PB, UK
Tel: +44 (0)20 7738 5454 Email: [email protected] Web: www.markallengroup.com
S2 J O U R N A L O F WO U N D C A R E V O L 2 3 N O 5 A AW C / AW M A / E W M A D O C U M E N T 2 0 1 4
Contents
Abstract 4
Introduction 5
Project aim 5
Project objectives 5
Overview of the document 6
The problem of wounds 7

Teamwork – a historical overview 7
Definition of commonly used terms 8
The definitions as they apply to wound care 9
Clinical evidence for managing wounds as a team 11

Introduction 11
Literature search outcomes 11
A team approach in wound care – methods of included studies 11
A team approach in wound care – study populations 13
A team approach in wound care – care settings 13
A team approach in wound care – team interventions 14
A team approach in wound care – primary outcomes measures 16
A team approach in wound care-– secondary outcomes 16
A team approach in wound care – methodological issues within studies 17
Summary 17
Barriers & facilitators 19

The ‘will’ of participating clinicians 19
The pragmatics of service delivery 22
Determining client need 22
Team location 22
Team communication 23
Accessing the medical record 24
Clinician remuneration 24
Reported changes to the cost-benefit ratios 25
Conclusions 25
Universal model for the team approach to wound care 26

Summary 31
Summary and conclusion 32

References 34
J O U R N A L O F WO U N D C A R E V O L 2 3 N O 5 A AW C / AW M A / E W M A D O C U M E N T 2 0 1 4 S3
Abstract
Background Method
The growing prevalence and incidence of non- An integrative literature review was conducted.
healing acute and chronic wounds is a worrying Using this knowledge, the authors arrived at a
concern. A major challenge is the lack of united consensus on the most appropriate model to adopt
services aimed at addressing the complex needs and realise a team approach to wound care.
of individuals with wounds. However, the WHO
argues that interprofessional collaboration
in education and practice is key to providing Results
the best patient care, enhancing clinical and Eighty four articles met the inclusion criteria.
health-related outcomes and strengthening the Following data extraction, it was evident that
health system. none of the articles provided a definition for
the terms multidisciplinary, interdisciplinary or
It is based on this background that the transdisciplinary in the context of wound care.
team approach to wound care project was Given this lack of clarity within the wound care
conceptualised. The project was jointly literature, the authors have here developed a
initiated and realised by the Association for the Universal Model for the Team Approach to Wound
Advancement of Wound Care (AAWC-USA), the Care to fill this gap in our current understanding.
Australian Wound Management Association
(AWMA) and the European Wound Management
Association (EWMA). Conclusion
We advocate that the patient should be at the
heart of all decision-making, as working with the
Aim Universal Model for the Team Approach to Wound
The aim of this project was to develop a universal Care begins with the needs of the patient. To
model for the adoption of a team approach to facilitate this, we suggest use of a wound navigator
wound care. who acts as an advocate for the patient. Overall,
we feel that the guidance provided within this
document serves to illuminate the importance of
Objective a team approach to wound care, in addition to
The overarching objective of this project was to providing a clear model on how to achieve such
provide recommendations for implementing a an approach to care. We look forward to gathering
team approach to wound care within all clinical evidence of the impact of this model of care on
settings and through this to develop a model for clinical and financial outcomes and will continue
advocating the team approach toward decision to share updates over time.
makers in national government levels.
Introduction
C
hanging population demographics (AWMA) and the European Wound Management
resulting in an increased prevalence and Association (EWMA).
incidence of multisystem chronic diseases
means that health care services are continuously
challenged to provide increasingly complex Project Aim
interventions with limited resources, coupled The aim of this project was to provide a universal
with a decreasing availability of suitably qualified model for the adoption of a team approach to
health professionals.1 Patient safety is at the wound care.
centre of all health-care interventions, meaning
that health care providers have to demonstrate
an evidence-based, cost-effective and efficient Project objectives
rationale for the choice of specific care pathways The project objectives were to:
for individual patient groups.2 The WHO argues
that professionals who actively bring the skills • Conduct a systematic review of the literature to
of different individuals together, with the aim of identify the advantages and disadvantages of
clearly addressing the health-care needs of patients adopting a team approach to wound care;
and the community, will strengthen the health
system and lead to enhanced clinical and health- • Identify the definition of a team approach to
related outcomes.3 Indeed, a number of systematic wound care;
reviews have noted a positive impact in the use
of multidisciplinary interventions for chronic • Identify the barriers and facilitators to adopting a
diseases such as heart failure and mental illness, team approach to wound care;
and in individuals at risk of poor nutrition.4-6 These
positive outcomes relate to reduction in hospital • Provide recommendations for implementing
admissions, mortality and incidence of heart a team approach to wound care within the
failure as well as fewer suicide-related deaths, less clinical setting;
dissatisfaction with care, fewer drop-outs and an
overall reduction in the length of hospital stay. • Provide a tool for advocating a team approach to
wound care towards decision-makers at national
It is based on this background that the government levels;
team approach to wound care project was
conceptualised. The project was jointly • Create a basis for collaboration between
initiated and realised by the Association for the organisations and institutions working with
Advancement of Wound Care (AAWC-USA), the clinical conditions that benefit from the team
Australian Wound Management Association approach to wound care;
• Contribute to current initiatives aiming to as a team. In this section, the methods of the
strengthen integrated care processes such as the included studies in this document are outlined. This
European Innovation Partnership on Active and is followed by a discussion of the study populations,
Healthy Aging. care settings, team interventions, primary and
secondary outcomes and methodological challenges
within the included studies. Section three addresses
Overview of the Document the barriers and facilitators to achieving a team
This document is divided into four sections; approach to wound care. The focus of this section
the first section provides an overview of the is on the will of participating clinicians and the
interdisciplinary team approach. In doing so, pragmatics of service delivery. The fourth section
this section begins by addressing the problem proposes a universal model for a team approach
of wounds, followed by a historical overview of to wound care and in doing so, elaborates on
teamwork. A definition of commonly used terms the key considerations in striving for such a
is then provided with a discussion of how these model of care. Finally a summary and conclusion
definitions apply to wound care. Section two is provided, bringing the salient points of the
explores the clinical evidence for managing wounds document together.
The problem
of wounds
F
rom a wound care perspective, the growing wound care team can substantially improve clinical
prevalence and incidence of non-healing outcomes and reduce unnecessary morbidity and
acute and chronic wounds is a worrying mortality.12, 13 However, despite this evidence,
concern. Indeed, the incidence of wounds in the reports on the use of focussed interdisciplinary
EU-27 is approximately 4 million and a further wound care teams is scarce within the literature,
2 million patients acquire nosocomial (hospital- with disparity existing as to what the term
acquired) infections each year.7 Additionally, is ‘interdisciplinary’ means, and who exactly is
it estimated that more than 23% of all hospital eligible to be a member of this interdisciplinary
in-patients have a pressure ulcer and most pressure wound care team.14
ulcers occur during hospitalisation for an acute
episode of illness/injury.8 The cost of just one
problematic wound is between €6650–€10000 per Teamwork – A historical
patient, and the total cost of wound care accounts overview
for 2–4 % of European health care budgets.9 An interesting paper by Hasler15 provides a
Furthermore, 27–50% of acute hospital beds are historical overview of the development and
likely to be occupied on any day by patients with integration of the concept of health care teams
a wound.9 within primary care services in the UK. Hasler
argues that development of teamwork arose
One of the biggest challenges in wound care is the for many reasons beyond the actual desire of
lack of united services aimed at addressing all the individuals to start working together. For example,
health care needs of individuals with wounds.10 legislation surrounding the enhancement of
Indeed, more than a decade ago, Lindholm et the scope of practice of different team members
al.11 warned that lack of integrated wound care enhanced the potential for other team members to
services compounds the suffering of those with engage more actively in a team approach to care
wounds, which in turn substantially increases delivery. Furthermore, reimbursement systems
associated costs arising due to poorer outcomes provided specific funding for employing other
than could be expected with use of targeted members of the team. Changes were also made
wound care interventions. Conversely, focussed in the contractual systems which made enhanced
patient screening, followed by implementation competiveness a central component of ongoing
of appropriate care pathways, with close follow funding and patient willingness to engage with
up and monitoring by relevant members of the services offering such a team approach.
In the US, the Institute of Medicine16 has identified team members independently treat various issues a
an urgent need for high-functioning teams to patient may have, focusing on the issues in which
address the increasing complexity of information they specialise”.21
and interpersonal connections required in
contemporary healthcare. The transition of Interdisciplinary
practitioners’ from soloists to members of an “An interdisciplinary clinical team is a consistent
orchestra has gained national momentum grouping of people from relevant clinical
through healthcare reform with substantial disciplines, ideally inclusive of the patient, whose
interprofessional policy and practice development interactions are guided by specific team functions
in recent years. Best practice collaborations have
17
and processes to achieve team-defined favourable
identified the basic principles and values for team patient outcomes”.22
based care, and support for inter-professional
learning strategies is increasing16, 17. Transdisciplinary
“Transdisciplinary is the most advanced level,
From a wider legislative perspective, a greater focus and includes scientists, non-scientists, and other
on patient safety, combined with reduced resources stakeholders who go beyond or transcend the
available for health-care services has demanded a disciplinary boundaries through role release
re-evaluation of the approaches to care delivery. 18
and expansion”.18
One of the most important drivers for this change
is the increasing emphasis being placed on the The concept of multidisciplinarity therefore
adoption of person-centred approaches to care suggests the use of different disciplines to answer
delivery. At its essence, the adoption of a team
19
a particular clinical problem, but rather than
approach is argued as being fundamental to coming together, each discipline stays within
achieving these goals.18 However, one of the major their own boundaries.20 Conversely, the concept
challenges in moving from promoted to lived of interdisciplinarity suggests that there is a link
adoption of team work lies in the use of confusing, between the disciplines where each moves from
often interchangeable terminology that is poorly their own position into one collective group. This
understood, and even more poorly implemented group is then engaged in creating and applying
in practice.20 The terms multidisciplinary, new knowledge which exists outside of the
interdisciplinary, crossdisciplinary and disciplines involved.20 The fundamental difference
transdisciplinary are common terms found in the between the concept of transdisciplinary care
literature used to describe working in a team, yet and interdisciplinary care is the actual bringing
each term suggest different approaches and thus of new knowledge into the group through a
cannot and should not be used interchangeably. 18
transdisciplinary approach, and as such, this is
seen as the union of all interdisciplinary efforts.20
Definition of commonly Fundamentally, the central issue is that the group

used terms of relevant disciplines is such that the needs of
Multidisciplinary the patient group can be addressed appropriately.
“A multidisciplinary team is a group of health care Additionally, the group needs to truly work
workers who are members of different disciplines as a team to ensure that all the available skills
(professions e.g. psychiatrists, social workers), and expertise can be targeted in an appropriate
each providing specific services to the patient. The fashion. Importantly, the focus should be on
the patients’ needs and expectations. It is here ulcer*” OR “decubitus” OR “pressure area*”))))
therefore, that the significance of the word “team” OR (“leg ulcer*” OR “diabetic foot”))) AND
becomes evident. (((((((((“multidisciplinary”[All Fields]) OR
“interdisciplinary”[All Fields]) OR collaborat*)
A team is defined as OR interprofessional) OR “patient care team*”)
OR “care pathway*”) OR “care bundle*”)) OR
“A number of people with complementary “Patient Care Team”[Mesh])
skills who are committed to a common purpose,
performance goals, and approach for which Eighty four articles met the inclusion criteria
they are mutually accountable”. 23
(original research) and were data extracted using
the following headings:
Whereas, a team-based health care is defined as:
• Author
“Team based health-care is the provision of
health services to individuals, families and • Title
or their communities by at least two health
providers who work collaboratively with patients • Journal
and their caregivers – to the extent preferred by
each patient – to accomplish shared goals within • Year
and across settings to achieve coordinated,
high quality care”16 • Country
Therefore, the reason why the term “team” is • Wound Type

important is because it is within this concept that
the members are focussed on working in such a way • Definition of the Multidisciplinary Treatment
to achieve a mutually agreed goal. Furthermore, Team (MDT)
the work of the team is interdependent and team
members share responsibility and are accountable • MDT Composition
for attaining the desired results.1
• Other
The definitions as they apply to Following data extraction, it was evident that none
wound care of the articles provided a definition for what was
A systematic search of the literature was conducted meant by multidisciplinary, interdisciplinary or
as follows: transdisciplinary in the context of wound care. The
focus of the articles tended to be on who exactly
• Database(s): Medline, PUBMED, CINAHL comprised the members of the team, rather than
the model upon which the composition of the
• Language: English team was based. Thus, there is a significant lack of
clarity within the wound care literature, meaning
• Search words: (((((((“Leg Ulcer”[Mesh]) OR that individual interpretation of the concepts
“Pressure Ulcer”[Mesh])) OR ((“pressure ulcer*” is highly likely and as such largely unhelpful in
OR “pressure sore*” OR “bed sore*” OR “bed guiding practice in the area.
Owing to this lack of clarity, the authors of this equally important, and this includes the patient, as
document propose the following terminology: in the absence of this understanding, the team will
“Managing Wounds as a Team”. The rationale for not function effectively. In addition, from a health
the choice of this terminology lies in the thought and social gain perspective, patients report higher
that there is evidence within the literature of an levels of satisfaction, better acceptance of care and
understanding of the meaning of the concept of improved health outcomes following treatment by
“team”. Furthermore, all members of the team are a collaborative team.24
Clinical evidence
for managing
wounds as a team
Introduction to reach consensus on 76 included publications.

Since the original 1990 Saint Vincent Declaration Publication years spanned 1995–2013, with a
mission to reduce the amputation rate in patients notable increase in the frequency of articles relating
with diabetes by 50%, diabetes care delivery by to managing wounds as a team (MWT) in the past
organised teams have been promoted as best six years. Journals which published MWT articles
practice, with many international guidelines on included nearly every wound-related specialty and
the care of diabetes and diabetic foot care following represented multiple professional sectors. Primary
suit. From a pressure ulcer perspective, recent authorship ranged across specialties with the
quality initiatives suggest that the prevention highest first author group noted as physicians for
and treatment of pressure ulcers should also be diabetic foot ulcers and nurses for pressure ulcers.
undertaken using a team approach. 11 In addition, The studies originated from 23 different countries
team interventions for leg ulcer care have been representing nearly every continent. The literature
advocated by clinical practice guidelines. 11 included diabetic foot ulcer care (n=31), pressure
An analysis of the recent literature on team ulcer care (n=24), chronic wound care (n=11) and
intervention depicted the current state of wound leg ulcer care (n=10). In the following part of this
care practice and suggests a vision for future wound chapter, the literature search outcomes will be
team development. The following section elaborates described in more detail.
on the outcomes of the literature search, providing
a synthesis of the published literature obtained. A Team Approach in Wound Care –
Methods of Included Studies
Studies pertaining to diabetic foot ulcers (DFU)
Literature search outcomes represented most of studies (n=31). Of these, the
We conducted a literature search as described in the majority explored outcomes in relation to the
introduction. The search produced 84 articles, with implementation of a team approach to DFU care
additional sources identified in index searches. Two guided by professional standards or guidelines.25–44
reviewers screened the identified titles, abstracts Study methodology varied considerably and
and then full text of all potentially relevant reports included case control studies, prospective and
Table 1. Clinical Practice Guidelines on wound care published by Professional Organisations
Professional Organisation / Guidelines on Wound Care Recommend

Team Approach?
Inpatient Management of Diabetic Foot Problems. Yes
UK/NICE Clinical Guideline 119 (2013) www.nice.org.uk/guidance/CG119
Foot Care Service for People with Diabetes Commissioning guide. Yes
Implementing NICE guidance (2006)UK/NICE Clinical Guideline CG10 www.nice.org.uk/guidance/CG10
Standards of Medical Care in Diabetes. Yes
American Diabetes Association. Diabetes Care 2001; 34: Suppl1.
Practical Guidelines on the Management and Prevention of the Diabetic Foot. Yes
Bakker K., Apelqvist J., Schaper, N. C.;on behalf of the International Working Group on the Diabetic Foot Editorial
Board , (2011) Diabetes Metab Res Rev 2012; 28(Suppl 1): 225–231.
National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes. Yes
(Part of the Guidelines on Management of Type 2 Diabetes) 2011.
Melbourne Australia. https://www.nhmrc.gov.au/guidelines/publications/di21
Registered Nurses’ Association of Ontario (RNAO). Risk assessment & prevention of pressure ulcers 2011 supplement. Yes
Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2011
http://rnao.ca/bpg/guidelines/risk-assessment-and-prevention-pressure-ulcers
Association for the Advancement of Wound Care (AAWC). Guideline of pressure ulcer guidelines. Yes
Malvern (PA): Association for the Advancement of Wound Care (AAWC); 2010.
http://aawconline.org/professional-resources/resources/
Association for the Advancement of Wound Care (AAWC) Venous Ulcer Guideline. Malvern (PA): Association for Yes
the Advancement of Wound Care (AAWC); 2010 Dec. http://aawconline.org/professional-resources/resources/
Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care Yes
protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012
https://www.icsi.org/_asset/6t7kxy/PressureUlcer.pdf
Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care Yes
protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012
https://www.icsi.org/_asset/6t7kxy/PressureUlcer.pdf
American College of Foot and Ankle Surgeons Diabetic Foot Disorders: A Clinical Practice Guideline. (2006) Yes
Journal of Foot and Ankle Surgery, Vol 45 (5): A1-A40.
2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Yes
Foot Infections; Clin Infect Dis. (2012) 54 (12): e132-e173
Management of Diabetes - A national clinical guideline 116 – Management of Diabetic Foot Disease.Scottish Yes
Intercollegiate Guidelines Network; 2010 http://www.sign.ac.uk/pdf/sign116.pdf
retrospective cohort studies, case series, retrospective team approach to care. Study periods ranged from
longitudinal observation, and descriptive 1–11 years.
approaches. Since the team approach has long
been established as the standard, withholding team Pressure ulcers (n=24) were the next most common
intervention would not be feasible, and therefore no wound type in the literature search. The majority
randomised controlled studies were found. Several of studies were descriptive and observational with
cohort studies measured outcomes before and the exception of one randomised intervention
after implementing or reorganising some form of trial. Chronic wounds studies (n=11) as an entity
have been clustered together by some study characteristics. The mean age in the skilled nursing
authors. The methodology in these studies varied setting study was 83 years,52 while the mean age
from descriptive program reports, review articles, for ambulatory settings was 50 years.53, 54 All reports
a retrospective review, a systematic review and a treated multiple wound types, with pressure ulcers
pseudo-randomised cluster trial. Articles pertaining being the primary type in the skilled nursing study52
to the management of those with leg ulcers were whereas diabetic –related ulcers were the dominant
also included (n=10). The study methodology varied wound type treated in community55 and integrated
from a randomised controlled trial, a controlled programs.56 Venous ulcers were most prevalent in
clinical trial, a randomized controlled pilot study, other ambulatory samples.53, 54 Gender distribution
prospective risk analysis study, retrospective reviews, was equitable in ambulatory settings53, 57 and the
case series and descriptive reports. majority of patients were female in the skilled
nursing setting.14 With many missing demographic
A Team Approach in Wound Care – variables in these reports, it is difficult to summarise,
Study Populations but from available data, the heterogeneity of
Together, the studies related to DFU27, 33, 34, 36, 44, 45 chronic wound populations is evident.
described over 3000 subjects and all reported
positive clinical outcomes after wound care team Pooling of the studies on leg ulcer patients together
interventions. Similarity was noted in gender led to the inclusion of over 1500 patients. Although
distribution (mean 62% male), age (mean=66), there were missing demographic data, the estimated
duration of diabetes (mean years = 15), HbA1C mean age was 65, with approximately 50% of the
levels (mean 8.3) and percentage with a neuropathic participants being female.58 Mean ulcer duration,
involvement (88%). Otherwise, there was pooled from 4 studies prior to intervention was
considerable heterogeneity in comorbidities, ulcer approximately 40 weeks, indicating a sample with
location, ulcer depth and infection of subjects. longer duration ulcers.59-62
Comparable variability has been seen in other
multi-center reports46, which underscores the A Team Approach in Wound Care –
inherent heterogeneity of the disease. Care Settings
The team approach to diabetic foot ulcer care has
Because most reports of pressure ulcer team been studied in many clinical settings across the
interventions were related to institutional program care continuum. Much of the evidence comes
changes rather than individual patient effects, from integrated programs that manage patients
descriptions of the patient characteristics are vague. from primary prevention through to acute
Pooled patient characteristics from the skilled nursing hospital episodes and subsequent recovery.30–34
or rehabilitation settings revealed a mean age of 79, Of these, most centres were based in university
majority female, greater than 85% with mobility or medical centre hospitals where grouping of
restrictions, greater than 70% incontinent of urine professionals from multiple specialties is more
and greater than 50% with feeding dependence.47-50 easily accomplished. Other authors described
This reflects a representative population similar the team approach as a consultation service in
to the institutionalised elderly.51 Study participant an acute hospital setting25, 29 and in ambulatory
characteristics in acute care were sparse. diabetic foot ulcer clinics, and others described the
standardisation of a team approach to foot care
The pooled study population for chronic wounds across a network of ambulatory care clinics, which
includes over 6000 patients, with widely variable included urban, suburban and rural settings.27, 36, 63, 64
Figure 1. Frequency of specific team members rehabilitation centers (n=7), other settings were
cited in the literature paediatric (n=1) and a spinal cord outpatient
clinic (n=1). For venous leg ulcers all of the
Managing wounds as a team included studies were conducted in an outpatient
(Summary of role prevalence from literature 1995–2013)
setting, either in a wound centre or in the home
1%
care setting.
3%
7%
Nursing* Several investigators explored the site of care
5% 29% Surgeons* delivery as a variable in leg ulcer healing. For
Physicians*
example, Edwards et al.,61 in a randomised
Podiatrists*
14% Rehabilitation* controlled pilot study, found significantly increased
Nutrition healing rates in an intervention group treated
Social sciences* within a team approach to ulcer care, including
Administrative*
9% group community support, when compared with
Patient/Family
17% ulcer care delivered by a team in the home setting.
*includes all specialities Harrison et al.60 established a team of specialised
15%
nurses with equipment and referral linkages and
examined leg ulcer healing rates in the home
setting, before and after the new team deployment,
and found statistically significant differences in
leg ulcer healing rates in the post intervention
The benefit of a team approach to diabetic foot cohort. In a subsequent trial Harrison et al.68 found
ulcer care has also been demonstrated irrespective that specialised nurse team outcomes were similar
of the setting. In a claim-based analysis of Medicare in patients randomised to the home care setting
recipients in the U.S., Sloan et al.65 studied 189,598 or clinic based care. The investigators therefore,
individuals with diabetes-related lower extremity concluded that it was the organisation of care,
conditions for over 6 years. The authors found that delivered by evidence based trained teams that
patients who visited a podiatrist, in combination influenced healing rates, rather than the setting of
with one other lower extremity specialist, were less care itself.
likely to undergo an amputation than those who
did not have multiple care providers. Underlying Chronic wound care teams have been assembled
these results is the assumption that receiving in settings across the continuum of care delivery.
care from multiple specialists results in more In this review, five programs were described in
coordinated care. the outpatient setting.53–55, 66, 67 Other settings were
the acute care hospital,56, 69 a continuum between
Financial outcome is also promoted as a benefit to hospital, rehabilitation and home, and a nursing
team intervention in the care of chronic wounds. home setting.57
Cost reduction has been achieved through saving
clinician time,52 consolidation of services56, 57, 66 and A Team Approach in Wound Care –
downstream revenue production.67 Team Interventions
A summary of the frequency of specific team
The majority of pressure ulcer studies took place members cited in the evidence within this
in acute care hospitals (n=15) or skilled nursing document is seen in Table 2. From the diabetic foot
ulcer perspective, team membership varied from cases, including the use of innovative technologies
2 to 10 members and often included additional and the provision of education and training for
collaborators such as “primary care team”, other centres.
“home care nursing service” “research team” and
“administrators”. The types of team intervention Within the pressure ulcer literature, the majority of
varied across the spectrum, i.e. the joint surgical studies described team facilitation of a new pressure
approach, service model approach, integrated ulcer prevention program.47, 72-80 All the programs
disease management and various lean approaches. were multifaceted, often “bundle focused”, and
used quality improvement methodology without
Armstrong et al. conceptualised the team as a
28
a control group. Team functions included risk
podiatric and vascular surgery, “toe and flow” Dyad, assessment, conducting surveys, product evaluation,
with this collaborative model being supported by education, documentation, providing wound
some researchers.43 Conversely, others employed care treatments and planning continuity of care.
a wider team support network, such as case Multiple interventions were undertaken, but little
management, diabetes education, endocrinology, attempt was made to ascertain what elements,
hospitalists, infectious disease, nursing, prosthetics or group of elements, contributed most to the
and social work.30 Importantly, it was stressed that outcome. Therefore, other concurrent factors
this collaboration should follow the DFU patient may have influenced pressure ulcer reduction, for
through their complete episode of ulceration example, changes in clinical practice, electronic
and across all care settings, in order to ensure medical records, and new technology or
maximum outcomes.32, 35 specialtybeds.
Another approach is termed a “service model”31 For chronic wounds, in general, the team approach
where intervention components arise from broad focussed on centralisation and standardisation
standards and a clear patient focus. Combined of expertise and services.98 Team interventions
with performance measures, clinical research and were described as clinical (assessment, diagnosis,
education, the model claims an association between provision of care), preventive, scientific and
interventions and decreased lower extremity educational.14, 53-56, 66, 67, 69 Preventive services
amputations. This approach is supported by others involved primary care telemedicine screening56,
who employed flow sheets, standing orders and compliance monitoring55 and quality improvement
algorithms to guide care. 63
monitoring.69 Consistent clinical data collection
provided outcome management and scientific
A further approach using a minimal, intermediate research opportunities to assess evaluation of
and maximal model of diabetic foot care have been interventions and team impact53-56, 67. Knowledge,
described by the International Working Group for skills and clinical expertise of the team was fostered
the Diabetic Foot.70, 71 This model centres around through education, provided both internally and
the specific needs of the diabetic patient, beginning externally to the organisation.56, 69, 81
with the provision of preventative care and minor
wound care in the minimal domain, moving to The size and arrangement of teams related to leg
more advanced assessment, diagnosis, prevention ulcer care tend to be leaner than other teams. In
and treatment in the intermediate domain, with the studies reviewed it was common for care to be
the maximal domain concentrating on advanced planned and delivered by specialty nurse teams with
prevention and management strategies for complex expanded skills and referral linkages both within
the community and home care settings.61, 82, 83 Other 72-76, 86-88
A reduction in pressure ulcer prevalence
studies 59, 60, 68, 82, 84
demonstrated that partnerships after team intervention was reported in all of the
among different specialities such as nursing, studies, with a wide range of variation in starting
podiatry, dermatology or gerontology, yielded prevalence (4.85-41%) and in post prevalence (0-
favourable healing rates, when compared with care 22%) and no reported statistical significance levels.
delivered by a single team speciality.
A group of reports from chronic wounds report
A Team Approach in Wound Care – healing rates as a primary outcome. For example,
Primary Outcomes Measures Brown-Maher53 described an overall 34% wound
For studies related to the diabetic foot, the primary healing rate for 398 patients over 2 years. Similarly,
outcome measure was the rate of lower extremity Sholar et al.54 reported an overall 38% wound
amputation. The included studies all identified a healing rate over 7 years. Other reports claim
reduction in amputation rates; for example, in one healing rates by aetiology such as 60% over 12
study, total amputation rate per 10,000 people
37
months for recalcitrant leg ulcers56 and an 8-week
with diabetes fell by 70% (from 53.2% to 16.0%) average healing time for venous ulcers.55
and major amputations fell by 82% (from 36.4%
to 6.7%). A further study26 found a progressive Leg ulcer outcomes were primarily measured by
decrease in the total incidence of amputations healing rates.59, 60, 68, 82, 84, 89 For example, Akesson59
per 100,000 general populations from 10.7 in found a pre healing rate of 23%, compared with an
1999 to 6.24 in 2003. In yet another study,27 the 82% healing after a team approach. A further study84
high/low amputation ratio decreased from 0.35 found that 72% of patients healed with an average
to 0.27 due to an increase in low level (midfoot) time of 12.1 weeks following a team approach.
amputations (8.2% vs 26.1%, p<0.0001; OR=4.0,
95% CI 2.0–83.3). A 45.7% reduction in below-knee A Team Approach in Wound Care -–
amputations was also observed. Weck et al.85 studied Secondary Outcomes
the outcome of a structured system of diabetic Additional outcome measures have been studied to
foot care encompassing outpatient, inpatient determine the benefits of team intervention on DFU
and rehabilitative treatments. Participants were care within specific foot clinics.33-36 DFU healing
followed prospectively over 8 years and compared rates of 50%90, 55%, 65.7%36 70%90, 76.19%35
to control subjects treated without interdisciplinary and 90%34 were reported after follow up periods
care in another region of Germany. The structured of 10 weeks90 and 6, 1236 and 2935 months across
integrated team care resulted in a 75% reduction a number of studies. Reference healing rates in
of major amputations compared to standard care. DFU have been shown to be 48%–58% healed at
Finally Yesil et al.44 reduced major amputations 20 weeks91, as evidenced from a trial of 74 wound
from 20.4% to 12.6% (p=0.026) with the use of a centres. By comparison, the largest two studies that
team approach. followed healing rates until healing or death,33, 34
reported healing rates of 74% and 90%, over a mean
A number of published studies describe the of 27 and 18 weeks, respectively.
organisation of pressure ulcer teams with the
primary outcome assessed by pressure ulcer rates For the diabetic foot, two studies explored the
measured before and after team initiation. These outcome of self-care behaviour performance after
rates tended to be measured by point prevalence an outpatient team approach to patient education.
surveys, undertaken either annually or quarterly.47, Anselmo et al.92 found that 90% of patients
performed all suggested ulcer prevention care, but duration studies confounded by coincident
less than 10% wore the provided footwear. A further initiatives,97 such as improvements in diagnostic
study found that foot care behaviour improved
93
services and pharmaceuticals.
after 2 years (p<0.01) following patient education,
supplies provision and skills practice on a daily foot Evidence for the effect of the PU team is based
care regimen, compared to conventional diabetic mostly upon descriptive studies with PU prevalence
foot care and just 2 hours of education. Patient outcome data. Even though the reports are rich
satisfaction was another dimension explored as with detail about methods of team interventions
a secondary outcome.63, 94 Hjelm et al.94 found and interactions, the attribution of clinical outcome
that patients preferred the team structure and the solely to PU team involvement is not possible.
accessibility and cooperation of the foot team. Further, most of the studies focused on pressure
Furthermore, another study found that health ulcer prevention programs and not as much on
related quality of life (HRQOL) was enhanced in treatment approaches by the team.
terms of physical and emotional functioning63
following a team intervention. Despite the acknowledged limitations, the evidence
reviewed here provides a consistently positive
Patient satisfaction was also a secondary outcome measure of enhanced outcomes for patients with
measures explored among those with venous wounds of varying aetiologies when they are
ulceration with patient perception of services being managed using a team approach. Thus, it seems to
the outcome measure in one survey analysis of a be evident that a team approach is the best option
wound centre in Denmark.62 Indeed, in this single for managing individuals with the complex problem
study, 91% of patients were satisfied with quality of of wounds. Furthermore, with the availability of
technical care and empathy being the most valued well-defined clinical practice guidelines and the
by patients. existence of a large body of clinical studies, the
team approach to wound care should be amenable
A Team Approach in Wound Care – to standardisation.
Methodological Issues within Studies
Attribution of the consistently strong positive
clinical outcomes solely to team interventions Summary
remains difficult. As with most medical phenomena, A review and analysis of 18 years of literature
outcomes are likely to be associated with a vast related to managing wounds as a team revealed
array of contributing factors, including patient mounting evidence to support a team approach.
characteristics, site of care, composition of the When analysed according to wound types, literature
team and the precise measurement variables. related to diabetic foot ulcers comprises the largest
Furthermore, in diabetes care, comparison of body of knowledge, with many retrospective and
amputation rates may be challenging as result prospective reviews of long term programs, all
of variation in service provision, regional health demonstrating a positive team effect. Outcomes
practice, access to care and specialization density. 95
related to leg ulcer team care is supported by the
Global variation, ethnicity and population highest quality of evidence. Pressure ulcer team
heterogeneity have been shown to influence benefits are mostly supported by descriptive reports
variation in amputation incidence.96, 97 The of program outcomes. The team effect on chronic
duration of the study also influences the reduction wound care is supported by a systematic review with
of amputation incidence over time, with longer emerging additional literature describing positive
effects from care delivered by teams in dedicated review are reflective of the research limitations and
wound centres. challenges in wound research as an aggregate.
Outcome measures for all wound types are generally Additional research is needed to clearly
related to wound healing and amputation rates demonstrate the effect of the team approach to
with some additional qualitative, quantitative and wound healing, particularly relating to financial
patient-centred endpoints. All outcomes have been and clinical outcomes, owing to the current
reported positively, with no reports of negative challenges regarding reduced health budgets.
consequences of a team intervention. Furthermore, Patient sensitive outcome measures should also
the use of a team approach has been demonstrated be investigated with specific focus on patient
in all healthcare settings across the continuum. safety. Finally, exploration of the inter-professional
Overall, study populations have been representative educational opportunities in wound care will help
of the wound population at large. In addition, differentiate the skill set required to maximize
the methodological issues noted in this literature team function.
Barriers &
facilitators
T
he use of the multidisciplinary team in and their role within the multidisciplinary
the provision of cancer services has been team reference.
mandated in the UK, Australia, USA,
Canada and Hong Kong.98, 99 As a result, there Undergraduate programs tend to dedicate
is a growing body of literature describing the considerable resources to developing the technical
development of such teams and the outcomes skills of the graduate.100 For some professions
realised. It would appear that the development of (e.g. medicine, pharmacy) the ability to examine,
a multidisciplinary approach to care is strongly investigate, diagnose and treat the condition often
influenced by the ’will’ of the participating forms the focus of undergraduate endeavours. Less
clinician, the pragmatics of providing the service time is spent on the non-technical components
and the identified changes to the cost-benefit including communication techniques, teamwork
ratio reference. It is also evident that failing to practices and client-focussed care models. As these
address all three aspects simultaneously will result non-technical skills form the key foundations for
in, at best, clinician dissatisfaction and, at worst, multidisciplinary practice it can be postulated
long-term client complications reference. As we that some contemporary health care practitioners
move towards the delivery of multidisciplinary receive inadequate preparation for this form of
services for clients suffering from a wound, it is care. Equally, professions who give a greater focus
prudent to examine each of the above aspects and to the non-technical skills (e.g. nursing) may in
explore strategies to ensure that positive outcomes turn prevent their graduates from being an active
are realised. member of the decision-making processes within a
multidisciplinary team.101, 102
The ‘will’ of participating It is evident that if future graduates are to

clinicians provide multidisciplinary care they will need
The will of clinicians to participate in opportunities within their undergraduate study
multidisciplinary care is influenced by their programmes to develop the necessary skills.
educational preparation and professional While many education providers strive to
socialisation.3 The former will determine their achieve such experiences for their students, the
skills when they have to act as a member of pragmatics and funding constraints often limit
a multidisciplinary team, while the latter will the potentials. When Gardner et al.103 surveyed
determine their perception of other team members the attitudes of administrators responsible for
profession preparation within the United States, common goal of achieving safer and more patient-
they identified a number of barriers to providing centred outcomes.17 Although the content should
opportunities for students to participate in be present in all health professional undergraduate
multidisciplinary teams. Pragmatics such as programs, opportunities for experienced wound
aligning scheduled classes, the willingness of care clinicians to participate in such programs
students to work with other disciplines at a also need to be provided. As Barr stated,102 the
perceived cost to their own studies, and the clinicians need to be ‘competent to collaborate’.
different levels of student preparation were Many competencies are common or overlap with
frequently cited. Interestingly, the costs of more than one health profession and therefore,
providing such opportunities were often seen as enhancement of these collaborative competencies
an challenge that was difficult to meet within can extend the reach and effectiveness of the
contemporary budgets. entire team.107
As multidisciplinary wound care teams are formed, Whilst educational preparation of clinicians
time and resources to train health professions to participating in a multidisciplinary team is
work within a team will be needed. Roleplays, important, of equal importance is the attitude and
simulations and moderated case discussion are respect team members bring to the encounter.
strategies that enable the participant to focus on It is generally agreed that a key fundamental
the non-technical skills whilst communicating the to achieving multidisciplinary care is to ensure
technical data of the client being discussed.104–106 participant safety.108 This is achieved when
The goal of interprofessional learning is to prepare inter-professional respect and subsequent trust is
and encourage team members to work towards the developed between members.
Established hierarchical structures that perceive

the dominance of one profession over another
Figure 2. Narcissistic-Me Model (Modified from (e.g. medicine over allied health or nursing)
Dorahy & Hamilton 2009)116 often prevents participants from expressing an
Client alternative view for fear of being ridiculed.102, 108 In
contrary, members of a profession participating in
multidisciplinary activities may be ‘punished’ by
their professional peers for venturing beyond their
discipline and potentially undermining established
Majority of
descisions power bases.109
Some decisions
Me Team Health service organisations based on the political

framework described above create contests
Some decisions between participants, resulting in ‘winners and
Avoid decisions in losers’.110 The different funding models used
this quadrant for health care services provide an example of
this disparity. Population-based funding models
incorporating salaried health care workers
is believed to have the highest potential for
Me
supporting multidisciplinary teamwork.108 A focus
of generating income to support the organisation care. If groups become too harmonious, there is a
is reduced with a population-based funding model risk of “groupthink” developing. This occurs when
and clinicians are more inclined to dedicate members have a strong feeling of solidarity and
time to client interactions and team meetings are prepared to defend the group from internal
required for multidisciplinary practice. A ‘fee for and external ‘attack’.116, 117 Maintaining the group
service’ model changes the focus to one of income at all cost reduces the responsiveness of the group
generation. This model often reduces time spent to external opinion and internal difference of
with clients in order to maximise throughput and opinion. Furthermore, “groupthink” may prevent
perceives time dedicated to team meetings as a innovative approaches to client problems and
cost to the organisation. A fee for service model hamper effective referral mechanisms.
may also result in ‘gaming’ the system. Activities
that could reliably be performed by one health Dorahy and Hamilton116 suggested a method for
professional such as the nurse are undertaken by maintaining a professional identity whilst adopting
another health professional (doctor) as the fee for a team identity. The model called ‘The Narcissistic-
the latter is higher.108 This clearly works against We’ suggests that multidisciplinary teams operate
multidisciplinary practice where team members are on two continuums. The first is a “me-to-team”
able to contribute to the care of the client based on continuum and the second is a “me-to-client”
their expertise. continuum. The two continuums are placed at
right angles to form four quadrants of decision-
Multidisciplinary teams formed within a political making (Figure 2). The authors suggests that most
frame are more likely to be impacted by other decision should come from the “Client-Team”
gaming strategies. The transfer of hierarchical quadrant, but on occasions, some decisions will
structures and attitudes to the team often results in be required from the “Me-Client” and the “Me-
meetings structured as information dissemination Team” quadrants. In short, most decisions should
from the leader to the followers than a genuine be made by team and client collaborations, but
sharing and discussing of ideas. 109, 111–113
As a result, at times, health professionals will be required to
participants report that they learn to ‘play the game’ make decisions between themselves and the client
in an effort to have their opinion incorporated. The alone, or between themselves and the team alone.
team member makes subtle suggestions implying This suggests that effective multidisciplinary teams
that it was derived from the comments of the leader incorporate dynamics that work towards a team
and the leader then incorporates the suggestion and approach to client problems but maintain the right
presents it as their own idea.111–115 of individual members of the team (professional
or clients) to operate independent of “groupthink”
Having emphasised the importance of mutual when required.
respect within multidisciplinary teams, it is equally
important that the team members are able to Maintenance of professional identity is distinctly
maintain separate identities. Members are invited different than clinging to a single vision about
to the group to share their professional opinion. a clinical view. The “silo” approach suggests a
As a result, consensus may be reached about narrow and self-sufficient treatment system, able
treatment strategies or conversely, members may to stand alone without interference from other
agree to disagree. Being comfortable with differing disciplines. Contemporary healthcare complexities,
opinions from the team helps to ensure that the patient centred care and rapid advances in
group remains open to alternative approaches to knowledge preclude this approach from survival.
According to the 2012 Institute of Medicine of each professional is structured around an
report, several core personal values are necessary independent practice. A multidisciplinary wound
for individuals to function as effective members care service will require team-based systems that
of high-functioning teams. Described through may at times conflict with the above systems. The
“reality check” interviews with team members in geographic location of team members, the manner
a US collaborative, these values included honesty, in which they communicate, the time given to
discipline, creativity, humility and curiosity.16 communication and the system of remuneration
Maintenance of individual integrity and ethics requires innovative approaches to meet the needs
harmonises with collaborative competency for of the client and the multidisciplinary team.
effective team functioning.
Determining client need
Cleary, as multidisciplinary wound teams are The ability to assess multidisciplinary needs
formed, attention should be paid to educate of a client will require personnel with a broad
members on how to function as a team. Equally, a understanding of the services offered by different
regular review of the team dynamic will be needed professions and tools that facilitate accurate
to ensure that traditional professional boundaries assessment of client need. Whilst each profession
do not inhibit participation and that opportunities is able to determine how best they are able to meet
to maintain a professional identity, while adopting the client’s needs, their ability to determine the
a team identity, are incorporated. If this can multidisciplinary needs of the client are limited.
be achieved, the research suggests that client Further research is needed to develop assessment
satisfactions will be higher, as is job satisfaction for tools that accurately identify the services required
the health professionals. 118
by individual clients and the quantum required for
each service. Tools similar to the Kolb119 learning
Forming the multidisciplinary team is only one style inventory could be developed to determine
aspect of providing a multidisciplinary wound care the type and amount of service required (Figure 3).
service. Developing systems and resources that Once automated such systems could also generate
ensure the team function effectively is also essential. referrals and booking requests for the client. Into
the future, such systems could be available from
the web or other smart technology (e-health,
The pragmatics of service delivery m-health) that would facilitate self-assessment by
A multidisciplinary wound care service requires clients with complex wound needs.
access to a range of health professionals and
communication structures to facilitate inter- Team location
professional consultation. While the concept is When considering the location of the team
easy to understand, the pragmatics of delivering members the most obvious solution is to colocate
such a service are complex. Establishing the them within a given geographic area to improve
services required for a given client will require efficiency in the use of time and resources120–122
health care personnel that are familiar with Colocation of the multidisciplinary team is usually
the services provided by various team members structured around a centralised model of care.
and have an ability to construct individual care Multidisciplinary teams are located in large health
plans. Health professionals, by definition, are care institutions where the various disciplines
autonomous. While the need to collaborate are found. Often, such institutions are located
with other professionals is recognised, the work within metropolitan areas or large regional cities.
The client is required to attend the wound care Figure 3. Interdisciplinary inventory diagram
centre for treatment via personal or hospital
Treatment
provided transportation. By locating the team
close to their practice environment, limiting their
travel time and the housing of resources such as
wound products or investigative technologies
in a single location, efficiency will be enhanced.
However, such cost benefits analyses fail to
consider the personal cost experienced by the Acute Community
client. Additional transportation cost, time lost to
attend each consultation, and additional stresses
incurred often impose a person cost to the client’s
household budget.
Recent innovations in telecommunication Support

technology are now challenging the need
for centralised services. Telecommunication
technology has been available for some decades.
Voice or videoconferences now readily enable Team communication
team members to communicate whilst in different The ability for multidisciplinary teams to
locations. However, it is the development of communicate with each other is paramount. While
telehealth services and self-care technologies this can be facilitated by electronic options (e.g.
that are providing newer alternative models email, text, voice), many authors believe that time
for multidisciplinary teams.123–125 Telehealth and facilities must be found for the team to meet
services are traditionally seen as a technology face-to-face on a regular basis.98, 99, 102, 134 Regular
facilitated interaction between a clinician and multidisciplinary team meetings enable differing
the client while both are in different locations. treatment opinions to be discussed, outcomes to
However, more often, the interactions are be assessed from multiple perspectives and the
being expanded to include clinicians caring production of any future plans of care. A number
for the client at the local location. Three-way of considerations for facilitating these meetings
communication between the consulting clinician, are cited in the literature. Sufficiently focused time
the client and the local clinician facilitates is the most cited ‘must have’ for multidisciplinary
multidisciplinary practice.126-130 meetings. It is recommended that interruptions
from pagers, mobile phones, or other personnel are
Technology-facilitated self-help options have to be avoided during such meetings. It is further
exploded in recent years. Web resources or recommended that a regular time be scheduled for
applications for smart phone technologies multidisciplinary meetings. The meetings should be
now provide a wealth of preventative and seen as an integral part of the schedule of services
self-management strategies for the general similar to theatre or outpatient sessions. It is argued
public. The development of quality self help that where meetings are called on a needs basis, it is
information requires the collaboration of multiple too easy to be distracted by competing needs, or to
disciplines and as such is another form of find an excuse to be excluded by personnel that do
multidisciplinary practice.117, 123, 131–133 not support the model.102, 108, 134, 135
Opinion is divided over including the client in data transmission issues surrounding privacy and
the multidisciplinary meetings. If, as has been security may complicate access. If multidisciplinary
postulated, multidisciplinary care facilitates a care is to be facilitated, methods for ensuring access
client focus, then it would seem obvious that to a single medical record will need to be found.
the client should be included. Cited advantages The development of secure ‘cloud’ or web-based
of including the client and their family and data repositories may provide a solution. Equally,
friends in the meetings includes their ability to some of the social communication networks (e.g.
add additional information to the discussion, Facebook) may facilitate case discussion with the
to indicate an acceptance or not to proposed added advantages of including the client and his/
treatment strategies and to correct erroneous her family and friends.138 Clearly more research is
opinions, in addition to being able to provide needed in the rapidly expanding arena.
insight for the client on how the team works.99,
101, 136
However, others argue that including the Clinician remuneration
client in meetings hampers the ability of the The issue of remuneration and multidisciplinary
health professionals to state their opinion frankly. team function has been discussed above, but
Keeping the discussion at a level that does not the issues of fund distribution should also be
offend the client and his/her family may reduce considered under the pragmatics of providing a
the productivity of the group by stifling required service. If services are funded under population-
debate.99, 116 Most authors recommend a mixed based funding models, then a mechanism for
approach to team composition.99, 116 The client fund distribution will be required. One solution
and/or family should be included when relevant is to use the multidisciplinary care plan as the
and excluded when warranted. However, care criteria for remuneration. Professions providing
must be taken to avoid including the client the greater percentage of the services for the
only when information is to be imparted to client receive the higher percentage of the
them. This is a form of tokenism. It is, therefore, funding allocated for that client. Alternatively,
recommended that the client should be invited to the client is given the funds from which they
participate in the decision-making process and be purchase services from the team following a
confident that their opinions are heard. Remote period of consultation and plan development.
technologies described above provide flexible Both models work best for government support
avenues to achieve this interaction. services, such as the disability or palliative care
schemes found in Australia. In user pay or private
Accessing the medical record systems, similar distribution mechanisms could
In association with regular meetings, it is be used, but systems would be needed to deal
recommended that access to the same medical with the tensions arising between the need to
record for each client by the team is essential. generate income and the multidisciplinary needs
Paper based records are less than ideal, as they of the client.
require transportation or duplication to meet
the above aim. Electronic medical records (EPR) Reported changes to the cost-benefit ratios
are recommended as they facilitate an “enter- A number of studies have illustrated positive
once-view-by-many” approach.133, 137–144 When cost and client benefits from adopting a
the multidisciplinary team is located in a single multidisciplinary approach to care. Client
institution, access to EPR is often possible, but if outcomes including lower amputation rates,134
team members are located in different institutions, reduced pressure injuries145–147, faster healing
rates136 and reduced mortality rate following from engaging in multidisciplinary wound care.
trauma148 are examples of outcomes achieved for However, in order to achieve the benefits, a number
clients suffering from a wound. of factors would need to be implemented:
Organisational/financial benefits have been • Education about how to function within a

demonstrated across areas including infectious multidisciplinary team will be required for
diseases,149 pharmacy,150 diabetic foot63, 151 and all participants.
cardiac surgery.152 However cost-benefit needs to
be considered equally alongside patient outcomes • Team dynamics that overcome traditional
and efficiency of care. 152
A process-orientated professional boundaries and hierarchies will
multidisciplinary approach can have a major impact need to be implemented.
on the efficient utilisation of resources thereby
benefitting staff, the organisation and patients.63 • Team processes that facilitate group consensus
Indeed, a well-coordinated team approach has been whilst recognising the benefits of differing
shown to have positive effects on patient outcomes, opinions will be required
safety, efficiency and cost-effectiveness, supporting
organisational clinical activity across the service.152 • Work practices will need to change to facilitate
The overall benefit to the health system, the staff time for focused team meetings.
and the patient must be considered, as cost-benefit
is not always shown in the actual service or clinic • Protocols for client and family engagement will
but in the overall or long-term impact. need to be developed
Multidisciplinary teams can be created from • Communication systems including

existing services in an organisation. By working as telecommunication technologies will need to be
a team instead of a group of salaried individuals, explored and incorporated.
there is no increase in cost, but the efficiencies
created can provide significant savings.149 • Remuneration mechanisms that meet the needs
Standardised treatment with clear protocols of the client’s while recognising the need for
may have the added benefit of educating other the health professional to derive an income will
staff while utilising existing expertise in a need to be designed and implemented.
coordinated manner.148
• All changes are possible if the politic of
the health care provider, the clinicians and
Conclusions the client supports the intent, and they
There are demonstrated benefits for the client, the themselves are prepared to venture outside of
health care institution and individual clinicians traditional approaches.
Universal Model for
the Team Approach
to Wound Care
I
t is obvious that a ‘one model fits all‘ pathophysiology or psychological deficit requires
approach to building a team for the a major ‘mind shift’. It may mean that evidence-
provision of wound care is unrealistic. based treatment interventions, while incorporated,
Available resources, access to relevant expertise, take a ‘back seat’ to a more imaginative life-course
remuneration provisions and patient populations approach to healing wounds.
will always be context-specific. It is evident
however that the inclusion of key elements within Empowering the patient in this way assumes
wound care services will foster collaborations a certain level of patient knowledge. An
between different health care professionals and understanding of treatment rationales, insights
keep the needs of the patient in the forefront. into the health care system and mechanism of
The elements are depicted in Figure 4 and referral would be essential. In reality, the majority
described below. of patients are ignorant of such topics and some
would prefer not to know. Conversely, a recent
Essential to the successful provision of wound systematic review by Chewing et al154 has shown
care is a model that begins with the needs of the that over time, some patients increasingly prefer
patient. Viewing treatment options via a single to make shared decisions with their providers,
professional lens will quickly identify relevant though a minority still prefer to rely on providers
interventions but often fails to take into account to make the decisions around their specific
the patients’ goals or perceptions. A common care pathways.
case in point is the application of compression
therapy. The professional lens clearly makes It is clear that a patient-centred approach will
association between interstitial fluid accumulation require a patient advocate. For decades, midwifery
(oedema) and the physical mechanism of has employed a ‘birth partners’ model that
increasing hydrostatic pressure via compression provides the patient with a voice during the
bandages or garments to shift the fluid to the childbirth trajectory.155 While this system has
vascular compartment. The patient lens may received criticism about the ‘caliber’ of the birth
perceive compression therapy as an uncomfortable partner, often citing poor patient choices that
intervention that interferes with their normal have resulted in negative outcomes, if care systems
hygiene and daily activities, resulting in a low are to be predicted on patient perceived need,
compliance rate. 153
Formulating plans of care on this limitation will need to be recognised and
patient need in preference to foci of correcting mitigated against.
The suggested model here recognises the need Figure 4. Essential elements in an
for a patient advocate that is able to bring interdisciplinary wound care service.The
together the patients’ perceived needs, treatment patient forms the focus of the care but relies
aims and appropriate health care services into on the expertise of a wound navigator to
a management and care plan. Such a role is an organise wound care service via established
essential element of any wound team. Wound
referral mechanisms.The wound navigator and
navigators could be implemented in a number of
other health professionals either collaborate
to explore beneficial remuneration and health
configurations. If the model were to be completely
care systems and/or lobby to meet the needs of
patient driven, the patient would select their
the patient.
‘wound navigator’. This, however, may result in
the potential negative outcomes highlighted above
in the midwifery model of birth partner. The safer
option would be to instigate a wound navigator
Lobby
model that is focused on patient perceived needs

l
but draws from the expertise of health care na
o
s
ati
professionals. Wound navigators could be formal m Wound

rn
te
al o
partner
sys
roles created within the wound team similar

s loc
ion
to case management models used in palliative

Assessment
erat
Health care system
Referr
Healt h
Healt al
al mechanisms
care and mental health services.156-158 This would profe h

Remun
ssiona s s io n
help ensure adequate preparation of the wound l profe
al mechanisms
navigator and enable the collection of patient Patient

lth H
outcomes data that would, over time, highlight
Hea ional pro ealth Coll
Referr
fess abora
the importance of such roles in health care policy fe s
s iona tion
pro l
and remuneration schemes. Equally, it could be the
pro
al
He sional
pro ealth
ion
fes
first health professional approached by the patient.

alth
fess
H
Whilst this would require additional education

for all health clinicians (e.g. roles of other
health professionals, referral and remuneration
mechanisms) it will help to mitigate against
misconceptions arising from semi skilled or lay
advice, as seen in the midwifery model.
It is envisaged that wound navigators would not professionals to the total care of a patient. This
only advocate for individual patients, but would must be, in turn, complimented by referral
play an important role in lobbying for system mechanisms that recognise the contribution made
change. As suggested above, the collection of by the wound navigator. Such mechanism will
patient outcome data resulting from the model need to facilitate urgent review, case discussion
would provide evidence that could be used to and seamless transfer of patient records. Where
influence health policy, geographic allocation of such systems do not exist, the wound navigator,
resources and remuneration systems. This would, with support of other health professionals, would
in turn, improve the wound management received advocate for the development of the required
by individual patients. Thus, the wound navigator systems, or establish informal systems until the
would advocate for individual patients at the local former can be achieved. If adequate referral
level and for changes to wound management mechanisms are absent, the wound team model
systems at the context level. Both levels of postulated cannot be implemented.
advocacy would need the support of other health
care professionals from the wound team. In contemporary health care systems, the selection
of the participating professions for the provision of
The second essential element to a wound team a team approach to wound care is plagued by two
model is a clearly established referral mechanism. limitations. Firstly the selection is often based on
The wound navigator must understand the the most pressing needs; secondly, the selection is
contribution made by individual health based on the knowledge a referring clinician has
Figure 5. Graphic depiction of the needs of a patient suffering from severe burns.The graph
on the left depicts the quantum of care required along both continuums during the acute
phase of the healing process.The graph on the right depicts the patient’s needs during the
rehabilitation stage.
Physical needs Physical needs
• Tissue • Rehabilitation services

reconstruction • Assessment of living • Return to work -
• Fluid replacement arrangements • Tissue remodeling social work
Acute • Infection prevention • Fiscal resources Community Acute • Scar revision • Home modifications Community
care based care based
• Family counseling • Established support • Psychoses • Family counseling
services services services services
• Body image networks management • Coping with stigma
adjustment • Combatting
• Post trauma care depression
Psycho social needs Psycho social needs
of the role of the health professional the patient is the amount of each resource needed will continue
being referred to. Patients often describe the “run to be developed and should be incorporated into
around” experienced as they are referred from one such services.
health professional to another, often ending back
where their care started with no obvious benefit. The development of a patient-driven care system
The need for amalgamation of comprehensive remuneration comprises the next essential element
assessment data that identifies relevant health of the wound team model being recommended.
professions and services required by the patient Remuneration of health care services will be
justifies the requirement for a wound team model. heavily influenced by the local context. Some
will be a fee for service model and some will be
The assessment requires a combination of a population-based government funded model,
patient perceived needs and known health status while others will be a hybrid of both. Regardless of
parameters. It was further suggested that the the remuneration system, most are based on time-
assessment data should be presented as a graphic on-task (TOT) models. The health professional is
representation of the quantum of various services remunerated based on the time they spend with
required by the patient. Figure 6 is an example a patient. As presented in the barriers discussion
of the graphic representation suggested. It uses above, wound team care involves the use of time
assessment data to plot the quantum of services on patient-related matters but this time may
required by a patient on two continuums. The not always be directly spent with the patient.
first is a continuum between services traditionally For example, case discussions or team meetings
described as either acute or chronic. The second is are common exemplars. It is suggested that the
a continuum between physical and psychosocial formation of a wound team service will require a
need. It recognises that patients will often require revision of the remuneration model. While whole
services from all four quadrants but the quantum system reform will require the outcomes data
of each varies through out the wound-healing described above (see wound navigators), reform
journey. Each quadrant would be populated with can also be achieved by the professionals involved
wound management services identified within at the local level. Decisions to contribute unfunded
a local or national level. In this way the graphic time, pooling a percentage of fees into a team
representation would not only quantify the care budget, and/or additional patient private
amount of service required, it would also identified contribution to additional services can and should
required services. be instigated at the local level if the wound team
model is to be realised.
The development of such systems would enable
the provision of ‘care packages’ similar to other Another model for comparison is use of a cancer
chronic disease or disability services.159, 160 The navigator, which has resulted in patient-centred
bridge between existing assessment data collection improvements in coordination of services and
tools and the graphic representation depicted are referral patterns across the system.161 Another
currently still in development and not readily model using the navigator is the Transitional Care
available. However, the need for the wound team Model,162 which has demonstrated improvements
model to include a comprehensive assessment that in care coordination across settings of care for
highlights appropriate resources based on a whole patients with high risk diseases. These models
of life view would be required if such a service is to could be readily be applied to the chronic
be fully functional. In time, systems that quantify wound patient.
In the US, population health models of care that reform an imperative. Wound care providers will
promote continuity and coordination of services need to be active participants in these ongoing
include patient-centred medical homes (PCMH) reforms. Having a clear vision for effective wound
and accountable care organisations (ACOs). management provision will be an important
The PCMH promotes a continuous relationship element of this activity. The proposed model
between patients and providers to improve clinical we believe provides that vision. However, the
and financial outcomes. The ACO model lies in implementation of a wound team service should
the concept of shared savings, along with shared not wait until such reforms are realised. Clinicians
responsibility. Indeed, leveraging the value of wishing to establish the proposed wound team
primary care and empowering the patient to model can make changes to their local health care
improve and maintain the health of a population system that will help achieve the benefits suggested.
is the centre of US healthcare reform. In these Simple activities such as listing available wound
models, the primary care provider is the chief management services in the local area, establishing
navigator. 163
Within these systems, wound care networks and documenting referral mechanisms
consultation support must evolve to become would provide a foundation for changing the
more nimble and accessible, with clear alignment nature of a wound care service. Figure 5 is an
with the primary care navigators to produce the example of a service list with referral mechanisms
best outcome. that could be compiled by a clinician for a local
area. Creating such a repository and sharing it
Thus, cognisance of the American model described with other services in the local area increases
above, it is evident that the final essential element the treatment options available for patients.
is whole of health care system reform. It is Equally, establishing secure networks that enable
recognised that reforming the health care system is the sharing of a patient medical record between
an ongoing task confronting societies. Drivers such identified services, and if possible co-locating
as increasing health care demand and shrinking service systems, is a change that will foster a wound
fiscal resources are increasingly making health care team approach. Contemporary network repositories
Table 2. Example of a service list and referral mechanism that could be constructed
by a clinician for his/her local area to facilitate their role as a wound navigator.
Wound service Contact details Preffered referral Notes
Dr Ramston Ph: 5674532 Initial phone conversation Quick to respond
Mob: 013456 with follow up letter
Email: g.st@woundy
Feet for us podiatry Ph: 098765489 Refferal template supplied Wound debridement and
Mob: 0134567800 off loading
Email: [email protected]
High on you hyperbaric Ph: 011228976 Letter with patient details and Radiation cystitis, neuropathic
Mob: 01545454 payment status ulcer service
Super star plastic surgery Ph: 6722987 Letter with patient details and Scare review, surgical
Mob: 02897867 payment status debridement
such as data clouds provide a number of options for • Referral mechanisms that are responsive
sharing of professional opinions and secure patient
details. Social media networks also provide options • Aggregation of assessment data to form a
for patients to share their experiences with other single plan
similar patient cohorts, or for health professionals
to seek advice from worldwide networks, vastly • Appropriate remuneration systems
extending the notion of wound teams.
• A health care system sensitive to team models
Imaginative use of ‘ready to hand’ facilities provide
an avenue for exploring changes to a local health Each element can be realised either via health care
care system that can enhance wound management system reform or local collaboration. It has been
without having to wait for national health suggested that clinicians interested in establishing
care reforms. wound team services begin at the local level
by assuming the role of the wound navigator.
Figure 6 Example of a service list and referral Interested clinicians could generate a list of local
mechanism that could be constructed by a services, collaborate with identified services to
clinician for his/her local area to facilitate their develop referral mechanisms, aggregate assessment
role as a wound navigator. data collected by the services into to a whole
of system care plan, explore options for better
utilisation of existing remuneration schemes to
Summary fund identified patient need and collect outcomes
In summary, we believe that effective management data that supports the benefits of the wound team
of wounds as a team requires the development of approach highlighted in the literature. Over time,
five essential elements: the local initiatives suggested have the potential
to grow into a ‘groundswell’ of evidence that can
• A patient focus using an advocate for the patient be used to lobby government to instigate needed
– wound navigator health care reform.
Summary and
conclusion
C
hanging population demographics, with emphasis is on what the professionals involved in
the predicted increase in the numbers the care of the patient actually did, rather than the
of individuals with chronic diseases, model of care that underpins their intervention
means that there will be a corresponding increase strategies. It is for this reason that the concept
in the prevalence and incidence of wounds into “managing wounds as a team” was born, as it
the future. Therefore, not only will there be a was felt that this concept is well understood,
substantial need for wound management over the particularly as in other walks of life, teams are
coming decades, but there will also need to be a evident. The essence of the team approach in wound
concerted effort in developing good prevention management is that the team is interdependent
strategies in order to the reduce the unnecessary and team members share responsibility and are
complications of chronic disease. Diabetes is an accountable for attaining the desired results.
excellent example, where it is known that patient
education pertaining to foot care and offloading Regardless of how the teams are defined within
can substantially reduce the incidence of diabetic the literature, there is substantial evidence that
foot ulceration, a debilitating and life threatening when individual professionals come together with
complication of the disease. a shared goal that is patient focussed, enhanced
clinical outcomes can be achieved. This is evident
At the outset, adopting a team approach to the across the wound spectrum, clinical care settings
provision of wound management services seems and geographical locations. Furthermore, a wide
logical as no one profession has all the skills required variety of research designs have been employed,
to address the complex needs of individuals with all demonstrating positive results. Within the
wounds. However, a lack of clarity within the literature, the sustainability of a team approach
literature surrounding the terms multidisciplinary, was a concern, however, due to issues surrounding
interdisciplinary and transdisciplinary, means that reimbursement, scope of practice, and a general
to date, no consensus exists as to what is meant by lack of understanding of the role of other members
such approaches to care delivery. Therefore, it is of the team. It is for this reason that the Universal
not surprising that there have been challenges in Model for the Team Approach to Wound Care
implementing these models of care, when no one was developed. For this model to be successful, 5
really understands what they mean, or how they elements are required, ranging from use of a “wound
should best be achieved. Indeed, throughout the navigator”, to changes in referral and data collection
literature, no definitions are provided, rather the systems and to improved reimbursement approaches.
In addition, for this to be achieved, education and Overall, we feel that the guidance provided
training will be needed to facilitate individuals within this document, serves to illuminate the
developing the skills required to work together as a importance of a team approach to wound care,
team. We felt very strongly that the patient should and additionally provides a clear model on how to
be at the heart of all decision making; indeed, achieve such an approach to care. We look forward
working with the model begins with the needs of the to developing evidence of the impact of this model
patient. To facilitate this, we suggest use of a wound of care on clinical and financial outcomes and will
navigator, who acts as an advocate for the patient. continue to share updates over time.
References
1 World Health Organisation, Cinderella of Australian diabetes 19 Lutz, B., Bowers, B. Patient- 28 Armstrong, D.G., Bharara,
Working together for health, 2006. management? J Foot Ankle Res centered care: understanding its M., White, M., et al. The impact
Available from: www.who.int/ 2012; 5: 1, 24. interpretation and implementation and outcomes of establishing an
whr/2006/en/ [Accessed April 2013] in health care. Sch Inq Nurs Pract integrated interdisciplinary surgical
11 Lindholm, C., Bergsten, A., 2000; 14: 2, 165–183. team to care for the diabetic foot.
2 McLoughlin, V., Millar, J., Mattke, S., Berglund, E. Chronic Wounds and Diabetes Metab Res Rev 2012; 28:
et al. Selecting indicators for patient Nursing Care. J Wound care 1999; 20 Choi, B., Pak, A. Multidisciplinarity, 6, 514–518.
safety at the health system level in 8: 1, 5–10. interdisciplinarity and
OECD countries. Int J Qual Health transdisciplinarity in health research, 29 Canavan, R., Unwin, N., Kelly, W.,
Care 2006; 18: suppl 1, 14¬–20. 12 Patout, C., Birke, J., Horswell, services, education and policy: 1. et al. Diabetes and non-diabetes
R., et al. Effectiveness of a Definitions, objectives, and evidence related lower extremity amputation
3 World Health Organisation, comprehensive diabetes lower- incidence before and after the
of effectiveness. Clin Invest Med
Framework for action on extremity amputation prevention introduction of better organized
2006; 29: 6, 351–364.
interprofessional education & program in a predominantly diabetes foot care: continuous
collaborative practice. 2010. low-income African-American 21 Health Service Executive, longitudinal monitoring using
Available from: www.who.int/hrh/ population. Diabetes Care 2000; 23: Multidisciplinary team Health standard method. Diabetes Care
resources/framework_action/en/ 9, 1339–1342. Service Executive, 2013. 2008; 31: 3, 459–463.
[Accessed April 2013].
13 Dargis, V., Pantelejeva, O., 22 Wiecha, J., Pollard, T. The 30 Chiu, C.C., Huang, C.L., Weng,
4 Holland, R., Battersby, J., Harvey, Jonushaite, A., et al. Benefits of a Interdisciplinary eHealth Team: S.F., et al. A multidisciplinary diabetic
I., et al. Systematic review of multidisciplinary approach in the Chronic Care for the Future. J Med foot ulcer treatment programme
multidisciplinary interventions management of recurrent diabetic Internet Res 2004; 6: 3, e22. significantly improved the outcome
in heart failure. Heart 2005; 91: foot ulceration in Lithuania: a in patients with infected diabetic
899–906. prospective study. Diabetes Care 23 Katzenbach, J., Smith, D. The foot ulcers. J Plast Reconstr Aesthet
1999; 22: 9, 1428–31. Wisdom of Teams: Creating the Surg 2011; 64: 7, 867–872.
5 Naylor, C., Griffiths, R., Fernandez, High-performance Organization.
R. Does a multidisciplinary total 14 Vu, T., Harris, A., Duncan, Harvard Business School Press, 31 Driver, V.R., Madsen, J.,Goodman,
parenteral nutrition team improve G., et al. Cost effectiveness of 1993. R.A. Reducing amputation rates
outcomes? A systematic review. J multidisciplinary wound care in patients with diabetes at a
Parenter Enteral Nutr 2004; 28: 4, in nursing homes: a pseudo- 24 Mickan, S. Evaluating the military medical center: the limb
251–258. effectiveness of health care teams. preservation service model.
randomized pragmatic cluster trial.
Australian Health Review 2005; 29: Diabetes Care 2005; 28: 2, 248–253.
6 Simmonds, S., Coid, J., Joseph, P., Family Pract 2007; 24: 372–379.
2, 211-7.
et al. The Community mental health 32 El Sakka, K., Fassiadis, N.,
15 Hasler, J. The primary health care
team management in severe mental 25 Aksoy, D., Gürlek, A., Çetinkaya, Gambhir, R.P., et al. An integrated
team: history and contractual farces.
illness: a systematic review. Br J Y., et al. Change in the Amputation care pathway to save the critically
BMJ 1992; 305: 232–234.
Psychiatry 2001; 178: 497–502. Profile in Diabetic Foot in a Tertiary ischaemic diabetic foot. Int J Clin
16 Mitchell, P.H., Wynia, M.K., Reference Center: Efficacy of Team Pract 2006; 60: 6, 667–669.
7 Moore, Z. The war on wounds.
Golden, R., et al. Core Principles Working. Exp Clin Endocrinol 33 Elgzyri, T., Larsson, J., Thorne, J.,
Public Sector review: Europe 2012;
and values of effective team-based Diabetes 2004; 112: 9, 526–530. et al. Outcome of ischemic foot
24: 1–2.
health care, 2012, Institute of ulcer in diabetic patients who had
Medicine: Washington DC. 26 Anichini, R., Zecchini, F.,
8 European Pressure Ulcer no invasive vascular intervention.
Cerretini, I., et al. Improvement
Advisory Panel, summary report on Eur J Vasc Endovasc Surg 2013; 46:
17 I.E.C.E. Panel. Core of diabetic foot care after the
the prevalence of pressure ulcers. 1, 110–117.
Competencies for Interprofessional Implementation of the International
EPUAP Review 2002; 4: 2, 49–57.
Collaborative Practice: Report of Consensus on the Diabetic 34 Gershater, M.A., Londahl, M.,
9 Posnett, J., Gottrup, F., Lundgren, an expert panel, 2011: Washington Foot (ICDF): Results of a 5-year Nyberg, P., et al. Complexity of factors
H., et al. The resource impact of DC. prospective study. Diabetes Res related to outcome of neuropathic
wounds on health-care providers Clin Pract 2007; 75: 2, 153–158. and neuroischaemic/ischaemic
18 Newhouse, R., Spring, B.
in Europe. J Wound Care 2009; 18: diabetic foot ulcers: a cohort study.
Interdisciplinary evidence-based 27 Armstrong, D.G., Harkless, L.B.
4, 154–161. Diabetologia 2009; 52: 3, 398–407.
practice: Moving from silos to Outcomes of preventative care in a
10 Lazzarini, P., Gurr, J., Rogers, J., synergy. Nurs Outlook 2010; 58: 6, diabetic foot specialty clinic. J Foot 35 Hamonet, J., Verdie-Kessler, C.,
et al. Diabetes foot disease: the 309–317. Ankle Surg 1998; 37: 6, 460–466. Daviet, J.C., et al. Evaluation of a
multidisciplinary consultation of podiatry collaboration in high-risk 51 Moore, Z.,Cowman, S. Pressure approach. Acta Derm Venereol
diabetic foot. Ann Phys Rehabil Med diabetic and nondiabetic patients. ulcer prevalence and prevention 1995; 75: 2, 133–135.
2010; 53: 5, 306–318. The Operation Desert Foot practices in care of the older
experience. Diabetes Care 1999; person in the Republic of Ireland. J 60 Harrison, M., Graham, I.,
36 Jeffcoate, W.J., Chipchase, S.Y., 22: 5, 678–683. Clin Nurs 2012; 21: 3-4, 362–371. Lorimer, K., et al. Leg-ulcer care in
Ince, P., et al. Assessing the outcome the community, before and after
of the management of diabetic 44 Yesil, S., Akinci, B., Bayraktar, F., et 52 Vu, T., Harris, A., Duncan, implementation of an evidence-
foot ulcers using ulcer-related and al. Reduction of major amputations G., et al. Cost-effectiveness of based service. Can Med Assoc J
person-related measures. Diabetes after starting a multidisciplinary multidisciplinary wound care 2005; 172: 11, 1447–1452.
Care 2006; 29: 8, 1784–1787. diabetic foot care team: single in nursing homes: a pseudo-
centre experience from Turkey. Exp randomized pragmatic cluster trial. 61 Edwards, H., M, C., Finlayson,
37 Krishnan, S., Nash, F., Baker, Clin Endocrinol Diabetes 2009; 117: Fam Pract 2007; 24: 4, 372–379. K., et al. Improved healing rates for
N., et al. Reduction in diabetic 7, 345–349. chronic leg ulcers: pilot study results
amputations over 11 years in a 53 Brown-Maher, T. Multidisciplinary from a randomized controlled
defined U.K. population: benefits 45 Siersma, V., Thorsen, H., Holstein, approach to chronic wound care: trial of a community nursing
of multidisciplinary team work P.E., et al. Importance of factors our 2-year Newfoundland and intervention. Int J Nurs Pract 2005;
and continuous prospective audit. determining the low health-related Labrador experience. J Cutan Med 11: 4, 169–172.
Diabetes Care 2008; 31: 1, 99–101. quality of life in people presenting Surg 2009; 13 Suppl 1: S26–S28.
with a diabetic foot ulcer: the 62 Kjaer, M.L., Mainz, J., Sorensen,
38 Larsson, J., Apelqvist, J., Agardh, Eurodiale study. Diabet Med 2013; 54 Sholar, A., Wong, L., Culpepper, L.T., et al. Venous leg ulcer patient
C.D., et al. Decreasing incidence of 30: 11, 1382–1387. J.W., et al. The specialized wound priorities and quality of care:
major amputation in diabetic patients: care center: a 7 year experience at results of a survey. Ostomy Wound
a consequence of a multidisciplinary 46 Prompers, L., Schaper, N., a tertiary care hospital. Ann Plast Manage 2004; 50: 1, 48–55.
foot care team approach? Diabet Apelqvist, J., et al. Prediction Surg 2007; 58: 279–284.
Med 1995; 12: 9, 770–776. of outcome in individuals with 63 Rerkasem, K., Kosachunhanun,
diabetic foot ulcers: focus on the 55 Valdes, A.M., Angderson, C.,Giner, N., Tongprasert, S., et al. A
39 Madanchi, N., Tabatabaei-Malazy, differences between individuals J.J. A multidisciplinary, therapy- multidisciplinary diabetic foot
O., Pajouhi, M., et al. Who are with and without peripheral arterial based, team approach for efficient protocol at Chiang Mai University
diabetic foot patients? A descriptive disease. The EURODIALE Study. and effective wound healing: a Hospital: cost and quality of life. Int
study on 873 patients. J Diabetes Diabetologia 2008; 51: 5, 747–755. retrospective study. Ostomy Wound J Low Extrem Wounds 2009; 8: 3,
Metab Disord 2013; 12: 1, 36 [Epub Manage 1999; 45: 6, 30–6. 153–156.
ahead of print] 47 McNaughton, V.,Brazil, K. Wound
and skin team. Impact on pressure 56 Gottrup, F., Holstein, P., 64 Lazzarini, P.A., O’Rourke, S.R.,
40 Meltzer, D.D., Pels, S., Payne, W.G., ulcer prevalence in chronic care. J Jorgensen, B., et al. A new concept Russell, A.W., et al. Standardising
et al., Decreasing amputation rates Gerontol Nurs 1995; 21: 2, 45–49. of a multidisciplinary wound healing practices improves clinical diabetic
in patients with diabetes mellitus. An center and a national expert foot management: the Queensland
outcome study. J Am Podiatr Med 48 Jaul, E., A prospective pilot function of wound healing. Arch Diabetic Foot Innovation Project,
Assoc 2002; 92: 8, 425–428. study of atypical pressure ulcer Surg 2001; 136: 7, 765–772. 2006-09. Aust Health Rev 2012;
presentation in a skilled geriatric 36: 1, 8–15.
41 Rerkasem, K., Kosachunhanun, nursing unit. Ostomy Wound 57 Ennis, W., Meneses, P. Strategic
N., Tongprasert, S., et al. Reducing Manage 2011; 57: 2, 49-54. planning for the wound care clinic 65 Sloan, F.A., Feinglos, M.N.,
lower extremity amputations due in a managed care environment. Grossman, D.S. Receipt of care
to diabetes: the application of 49 Yap, T.L., Kennerly, S.M., Simmons, Ostomy/Wound Management and reduction of lower extremity
diabetic-foot protocol in Chiang M.R., et al. Multidimensional team- 1996; 42: 54–60. amputations in a nationally
Mai University Hospital. Int J Low based intervention using musical representative sample of U.S.
Extrem Wounds 2008; 7: 2, 88–92. cues to reduce odds of facility- 58 Fife, C.E., Carter, M.J., Walker, Elderly. Health Serv Res 2010; 45: 6
acquired pressure ulcers in long- D., Thomson, B. Wound Care Pt 1, 1740–1762.
42 Valabhji, J. Reducing amputations term care: a paired randomized outcomes and associated cost
at a multidisciplinary diabetic foot intervention study. J Am Geriatr Soc among patients treated in US 66 Ratliff, C.,G, R. The chronic
clinic in London. Diabetic Foot J 2013; 61: 9, 1552–1559. outpatient wound centers: data wound care clinic: “one stop
2011; 14: 2, 63–4, 66, 68. from the US wound registry. shopping”. J Wound ostomy
50 Nobrega, P., Rochon, P., Young, Wounds 2012; 24: 10–17. Continence 1995; 22: 2, 77–80.
43 Van Gils, C.C., Wheeler, L.A., W., et al. Effectiveness of a pressure
Mellstrom, M., et al. Amputation ulcer team at the bedside. Can 59 Akesson, H., Bjellerup, M. Leg 67 Kim, P.J., Evans, K.K., Steinberg, J.S.,
prevention by vascular surgery and Nurs Home 2009; 20: 2, 23–25. ulcers: report on a multidisciplinary et al. Critical elements to building
an effective wound care center. J study implementing standardized 90 Fitzjohn, M., Gibson, H.,Spruce, 101 V Lloyd, J., Schneider,
Vasc Surg 2013; 57: 6, 1703–1709. nurse aide documentation and P. Wound care. Setting up a foot J., Scales, K., et al. Ingroup
feedback reports. Adv Skin Wound clinic. Nurs Times 1996; 92: 11, identity as an obstacle to
68 Harrison, M.B., Graham, I.D., Care 2010; 23: 3, 120–131. 76–80. effective multiprofessional and
Lorimer, K., et al. Nurse clinic versus interprofessional teamwork: findings
home delivery of evidence-based 79 Jaul, E. Setting up a dedicated 91 Kurd, S.K., Hoffstad, O.J., Bilker,
from an ethnographic study of
community leg ulcer care: a pressure ulcer unit in a geriatric W.B., et al. Evaluation of the use
healthcare assistants in dementia
randomized health services trial. ward. J Wound Care 2003; 12: 4, of prognostic information for the
care. J Interprof Care 2011; 25: 5,
BMC Health Serv Res 2008; 8: 243. 131–133. care of individuals with venous leg
345–351.
ulcers or diabetic neuropathic foot
69 Lancellot, M. CNS combats 80 Russell, T., Bsn, A.L.,Lohman, J.A. ulcers. Wound Repair Regen 2009; 102 Atwal, A., Caldwell, K. Nurses
pressure ulcers with skin and A medical center’s experience with 17: 318–325. perception of multidisciplinary team
wound assessment team (SWAT). managing specialty bed usage. J
work in acute care. Int J Nurs Pract
Clin Nurse Spec 1996; 10: 3, Wound Ostomy Continence Nurs 92 Anselmo, M.I., Nery, M.,Parisi,
2006; 12: 6, 359–365.
154–160. 2001; 28: 6, 274–278. M.C. The effectiveness of
educational practice in diabetic foot: 103 Gardner, S., Chamberlin, G.,
70 International Diabetes 81 Campbell, K., Teague, L., Hurd, T., a view from Brazil. Diabetol Metab Heestand, D., et al. Interdisciplinary
Federation and the International et al. Health policy and the delivery Syndr 2010; 2: 1, 45. Didactic Instruction at Academic
Working Group on the Diabetic of evidencebased wound care using
Health Centers in the United
Foot, Time to Act. Put feet first, regional wound teams. Healthcare 93 Liang, R., Dai, X., Zuojie, L., et
States: Attitudes and Barriers. Adv
prevent amputations: diabetes and management Forum 2006; 19: 2, al. Two-year foot care program
Health Sci Educ Theory Pract 2002;
foot care, 2005. 16–21. for minority patients with type 2
7: 3, 179–190.
diabetes mellitus of Zhuang Tribe
71 van Acker, K., Employing 82 Gohel, M.S., Taylor, M., Earnshaw, in Guangxi, China. Can J Diabetes 104 Disch, J. Interprofessional
interdisciplinary team working J.J., et al. Risk factors for delayed 2012; 36: 1, 15–18. Education and Collaborative
to improve patient outcomes in healing and recurrence of chronic
94 Hjelm, K., Nyberg, P.,Apelqvist, J. Practice. Nurs Outlook 2013; 61:
diabetic foot ulceration – our venous leg ulcers--an analysis of
The diabetic foot -- multidisciplinary 1, 3–4.
experience. EWMA Journal 2012; 1324 legs. Eur J Vasc Endovasc Surg
12: 2. 2005; 29: 1, 74–77. management from the patient’s 105 Schopf, T.,Flytkjaer, V.
perspective. Clin Effect Nurs 2002; Doctors and nurses benefit from
72 Armour-Burton, T., Fields, W., 83 Ettridge, E. A multidisciplinary 6: 2, 66–77. interprofessional online education
Outlaw, L., et al. The Healthy Skin approach to leg ulcer prevention.
95 Connelly, J., Airey, M.,Chell, in dermatology. BMC Med Educ
Project: changing nursing practice to Comm Nurs 2000; 6: 1, 33–34.
S. Variation in clinical decision 2011; 11: 84.
prevent and treat hospital-acquired
pressure ulcers. Crit Care Nurse 84 Butters, T. Interdisciplinary making is a partial explanation for 106 Gottrup, F. Optimizing
2013; 33: 3, 32–39. chronic-wound care services geographical variation in lower wound treatment through health
involving podiatry - a strengthened extremity amputation rates. Br J care structuring and professional
73 Blaszczyk, J., Majewski, M.,Sato, F. model of care? Wound Pract Res Surg 2001; 88: 4, 529–535. education. Wound Repair Regen
Make a difference: standardize your 2011; 19: 4, 229–233.
96 Margolis, D.,Jeffcoate, W. 2004; 12: 2, 129–133.
heel care practice. Ostomy Wound
Manage 1998; 44: 5, 32–40. 85 Weck, M., Slesaczeck, T., Paetzold, Epidemiology of Foot Ulceration 107 Barr, H. Competent to
H., et al. Structured health care for and Amputation: Can Global collaborate: Towards a competency
74 Granick, M.S.,Ladin, D.A. The subjects with diabetic foot ulcers Variation be Explained? Med Clin
based model for interprofessional
multidisciplinary in-hospital wound results in a reduction of major North Am 2013; 97: 5, 791–805.
education. J Interprof Care 1998; 12:
care team: two models. Adv Wound amputation rates. Cardiovasc
97 Moxey, P.W., Gogalniceanu, P., 2, 181–187.
Care 1998; 11: 2, 80–83. Diabetology 2013; 12: 45, 1–9.
Hinchliffe, R.J., et al. Lower extremity
108 Pullon, S., McKinlay, E.,Dew,
75 Klingel, P., Exploring the process 86 Bankert, K., Daughtridge, S., amputations — a review of global
K. Primary health care in
of a skin care team. Ostomy Meehan, M., et al. The application variability in incidence. Diabet Med
New Zealand: the impact of
Wound Manage 1996; 42: 10, 30–4, of collaborative benchmarking to 2011; 28: 10, 1144–1153.
organisational factors on teamwork,
36–8, 40 passim. the prevention and treatment of
98 Lanceley, A., Savage, J., Menon, U., 2009. http://0-ovidsp.ovid.com.
pressure ulcers. Adv Wound Care
76 Milne, C.T., Trigilia, D., Houle, et al. Influences on multidisciplinary alpha2.latrobe.edu.au/ovidweb.cg
1996; 9: 2, 21–29.
T.L., et al. Reducing pressure ulcer team decision-making. Int J Gynecol i?T=JS&PAGE=reference&D=m
prevalence rates in the long-term 87 Fleischer, I.,Bryant, D. Evaluating Cancer 2007; 18: 215–222. edl&NEWS=N&AN=19275835
acute care setting. Ostomy Wound replacement mattresses. Nurs [Accessed April 2014].
Manage 2009; 55: 4, 50–59. Manage 1997; 28: 8, 38–41. 99 Lamb, B.W., Sevdalis, N., Benn,
J., et al. Multidisciplinary cancer 109 Coombs, M., Ersser, S.J. Medical
77 Tippet, A.W. Reducing the 88 Powers, J. A multidisciplinary team meeting structure and hegemony in decision-making - A
incidence of pressure ulcers approach to occipital pressure treatment decisions: a prospective barrier to interdisciplinary working
in nursing home residents: a ulcers related to cervical collars. J correlational study. Ann Surg Oncol in intensive care? J Adv Nurs 2004;
prospective 6-year evaluation. Nurs Care Qual 1997; 12: 1, 46–52. 2013; 20: 3, 715–722. 46: 3, 245–252.
Ostomy Wound Manage 2009; 55:
11, 52–58. 89 Milas, M., Bush, R.L., Lin, P., et al. 100 Kuhn, K.L., Rundle-Thiele, S.R. 110 Boden, D., Borrego, M.
Calciphylaxis and nonhealing wounds: Curriculum Alignment: Exploring Academic Deaprtments and
78 Horn, S.D., Sharkey, S.S., Hudak, the role of the vascular surgeon in Student Perception of Learning Related Organizational Barriers to
S., et al. Pressure ulcer prevention a multidisciplinary treatment. J Vasc Achievement Measures. IJTLHE Interdiscplinary Research. Higher Ed
in long-term-care facilities: a pilot Surg 2003; 37: 3, 501–507. 2009; 21: 351–361. Rev 2011; 8: 41–64.
111 Cypress, B.S. Exploring facilitatorsof multidisciplinary Unserved. Yearbook of Medical 141 Kannampallil, T.G., Franklin,
the concept of nurse-physician team working: a review. Peadiatric Informatics 2010; 94–100. A., Mishra, R., et al. Understanding
communication within the context Nursing 2008; 20: 2, 26–29. the nature of information seeking
of health care outcomes using the 132 Rooke, S., Copeland, J., behavior in critical care: implications
evolutionary method of concept 123 Alfaar, A.S., Kamal, S., Norberg, M., et al. Effectiveness of for the design of health information
Abouelnaga, S., et al. International a self-guided web-based cannabis technology. Artif Intell Med 2013;
analysis. Dimens Crit Care Nurs
telepharmacy education: another treatment program: randomized 57: 1, 21–29.
2011; 30: 1, 28–38.
venue to improve cancer care in controlled trial. J Med Internet Res
112 Fuller, W. The war on nursing the developing world. Telemed J E 2013; 15: 2, e26. 142 Keenan, G., Yakel, E., Dunn
continues: “Dr. title bill” is an insult Health 2012; 18: 6, 470–474. Lopez, K., et al. Challenges to nurses’
133 Scherpbier-de Haan, N.D., van
to nurses. Fla Nurse 2013; 61: 1, efforts of retrieving, documenting,
124 Lavery, G.G., Horan, E. Clinical Gelder, V.A., Van Weel, C., et al. Initial
and communicating patient care
2, 9.
review: communication and implementation of a web-based
information. J Am Med Inform
113 Selvam, A. Stiff resistance. Docs logistics in the response to the consultation process for patients
Assoc 2013; 20: 2, 245–251.
fight encroachment in turf war 1998 terrorist bombing in Omagh, with chronic kidney disease. Ann
with nurses. Mod Healthc 2013; Northern Ireland. Cric Care 2005; Fam Med 2013; 11: 2, 151–156. 143 Patterson, E.S., Zhang,
43: 16, 10. 9: 4, 401–408. J., Abbott, P., et al. Enhancing
134 Apelqvist, J., Ragnarson-
electronic health record usability in
114 Brinkman, A. Disparities 125 Yager, P.H., Cummings, B.M., Tennvall, G., Persson, U., et
pediatric patient care: a scenario-
undermine nursing. Nurs N Z 2013; Whalen, M.J., et al. Nighttime al. Diabetic foot ulcers in a
based approach. Jt Comm J Qual
19: 2, 30. telecommunication between multidisciplinary setting. An
Patient Saf 2013; 39: 3, 129–135.
remote staff intensivists and economic analysis of primary
115 O’Leary, K.J., Ritter, C.D., bedside personnel in a pediatric healing and healing with 144 Xie, C., Mills, H., Magill, J.,
Wheeler, H., et al. Teamwork on intensive care unit: a retrospective amputation. J Intern Med 1994; 235: et al. Reducing treatment delay
inpatient medical units: assessing study. Crit Care Med 2012; 40: 9, 5, 463–471. by improving information flow
attitudes and barriers. Qual Saf 2700–2703. within the multidisciplinary team: a
Health Care 2010; 19: 2, 117–121. 135 Ponte, P.R., Gross, A.H.,
muticycle audit spiral in head and
126 Benavides-Vaello, S., Strode, Milliman-Richard, Y.J., et al.
neck cancer. Clin Otolaryngol 2012;
116 Dorahy, M., Hamilton, G. A.,Sheeran, B.C. Using technology Interdisciplinary teamwork and
37: 5, 427–428.
The ‘Narcisstic-We” model: in the delivery of mental health and collaboration: an essential element
A conceptual framework for substance abuse treatment in rural of a positive practice environment. 145 Granick, M.S.,Ladin, D.A. The
multidisciplinary team working, communities: a review. J Behav Health Annu Rev Nurs Res 2010; 28, multidisciplinary in-hospital wound
researching and decision-making Serv Res 2013; 40: 1, 111–120. 159–189. care team: two models. Adv Wound
with traumatised individuals. Consel Care 1998; 11: 2, 80–83.
Psychother Res 2009; 9: 1, 57–64. 127 Cartwright, M., Hirani, S.P., 136 Gottrup, F. A specialized
Rixon, L., et al. Effect of telehealth wound-healing center concept: 146 Granick, M.S., McGowan,
117 Yalom, I.D.,Vinogradov, S. on quality of life and psychological importance of a multidisciplinary E.,Long, C.D., Outcome assessment
Bereavement groups: techniques outcomes over 12 months (Whole department structure and surgical of an in-hospital cross-functional
and themes. Int J Group Psychother Systems Demonstrator telehealth treatment facilities in the treatment wound care team. Plast Reconstr
1988; 38: 4, 419–457. questionnaire study): nested study of chronic wounds. Am J Surg 2004; Surg 1998; 101: 5, 1243–1247.
of patient reported outcomes in 187: 5A, 38S–43S.
118 Chang, W.Y., Ma, J.C., Chiu, a pragmatic, cluster randomised 147 Long, C.D., Granick, M.S.
H.T. et al. Job satisfaction and controlled trial. BMJ 2013; 346: f653. 137 Banfield, M., Gardner, A multidisciplinary approach to
perceptions of quality of patient K., McRae, I., et al. Unlocking wound care in the hospitalized
care, collaboration and teamwork 128 Chipps, J., Ramlall, S.,Mars, information for coordination of patient. Clin Plast Surg 1998; 25: 3,
in acute care hospitals. J Adv Nurs M. A telepsychiatry model to care in Australia: a qualitative study 425–431.
2009; 65: 9, 1946–1955. support psychiatric outreach in the of information continuity in four
public sector in South Africa. Afr J primary health care models. BMC 148 Leung, G.K., Ng, G.K., Ho, W.,
119 Kolb, D.A. Learning style Psychiatry 2012; 15: 4, 264–270. Fam Pract 2013; 14: 34. et al. Impact of a multidisciplinary
inventory: Technical manual. The trauma team on the outcome of
McBer and Company, 1976. 129 Gellis, Z.D., Kenaley, B., 138 Bridewell, W.,Das, A.K. Social acute subdural haematoma. Injury
McGinty, J. et al. Outcomes of network analysis of physician 2012; 43: 9, 1419–1422.
120 Cameron, A.,Masterson, A. a telehealth intervention for interactions: the effect of
Managing the unmanageable? Nurse homebound older adults with institutional boundaries on breast 149 Wolf, S., Leitritz, L., Rupp, C., et
Executive Directors and new role heart or chronic respiratory failure: cancer care. AMIA Annu Symp Proc al. Cost reduction after introduction
developments in nursing. J Adv a randomized controlled trial. 2011; 2011, 152–160. of a multidisciplinary infectious
Nurs 2000; 31: 5, 1081–1088. Gerontologist 2012; 52: 4, 541–552. disease service at a German
139 Dykes, P.C., DaDamio, R.R., university hospital. Infection 2000;
121 Danvers, L., Freshwater, 130 Plow, M., Finlayson, M., Motl, R.W., Goldsmith, D., et al. Leveraging 28: 6, 379–383.
D., Cheater, F. et al. Providing a et al. Randomized controlled trial of a standards to support patient-
seamless service for children with teleconference fatigue management centric interdisciplinary plans of 150 Pacey, S., Warner, J.,Li Wan Po,
life-limiting illness: experiences and plus physical activity intervention care. AMIA Annu Symp Proc 2011; A. A multidisciplinary approach
recommendations of professional in adults with multiple sclerosis: 2011: 356–363. to hospital-based drug cost
staff at the Diana Princess of Wales rationale and research protocol. BMC containment. J Clin Pharm Ther
Children’s Community Service. J Neurology 2012; 12: 122. 140 Jones, K.L., Jamerson, C., 1998; 23: 3, 203–211.
Clin Nurs 2003; 12: 3, 351–359. Pike, S. The journey to electronic
131 Akter, S.,Ray, P., mHealth - an interdisciplinary care plans. Nurs 151 O’Reilly, D., Hopkins, R.,
122 Doyle, J. Barriers and Ultimate Platform to Serve the Managet 2012; 43: 12, 9–12. Blackhouse, G., et al. Long-Term Cost-
utility Analysis of a Multidisciplinary 154 Chewning, B., Bylund, C.L., -a descriptive analysis of enquiries of Mental Health and Wellbeing.
Primary Care Diabetes Management Shah, B., et al. Patient preferences using a Case Management Process Aust N Z J Psychiatry 2002; 36: 2,
Program in Ontario. Can J Diabetes for shared decisions: a systematic Model approach. BMC Res Notes 210–216.
2007; 31: 3, 205–214. review. Patient Educ Couns 2012; 2012; 5: 611.
86: 1, 9–18. 161 McMullen, L. Oncology nurse
152 O’Regan, D., Shah, S., Mirsadraee, 158 van der Plas, A.G.M., Deliens, navigators and the continuum of
S., et al. Implementation of a process- 155 Hodnett, E.D., Gates, S., L., van de Watering, M., et al. cancer care. Semin Oncol Nurs
orientated multidisciplinary approach Hofmeyr, G.J., et al. Continuous Palliative care case management in 2013; 29: 2, 105–117.
(POMA), a system of cost-effective support for women during primary care settings: a nationwide
childbirth. Cochrane Database Syst survey. Int J Nurs Stud 2013; 50: 11, 162 Naylor, M.D.,Sochalski, J.A. Scaling
healthcare delivery within a cardiac up: bringing the transitional care
surgical unit. Qual Saf Health Care Rev 2011; 16: 2, CD003766. 1504–1512.
model into the mainstream. Issue Brief
2008; 17: 6, 459–463. 156 Beyea, A., Fischer, J., Schenck, 159 Henderson, E.J.,Caplan, G.A. (Commonw Fund) 2010; 103: 1–12.
A. et al., Integrating palliative care Home sweet home? Community
153 Shannon, M.M., Hawk, J., 163 Maeng, D.D., Davis, D.E.,
information and hospice referral in care for older people in Australia. J
Navaroli, L., et al. Factors affecting Tomcavage, J., et al. Improving
medicaid primary care. J Palliat Med Am Med Dir Assoc 2008; 9: 2, 88–94.
patient adherence to recommended patient experience by transforming
2013; 16: 4, 376–382.
measures for prevention of 160 Meadows, G., Singh, B., Burgess, primary care: evidence from
recurrent venous ulcers. J Wound 157 Kuhn, U., Dusterdiek, A., P., et al. Psychiatry and the need Geisinger’s patient-centered
Ostomy Continence Nurs 2013; 40: Galushko, M., et al. Identifying for mental health care in Australia: medical homes. Popul Health
3, 268–274. patients suitable for palliative care- findings from the National Survey Manag 2013; 16: 3, 157–163.
IO N REP
TAT © O
CI R
Journal of Wound Care (JWC) is the leading L
THOMSON
NA
TS
source of tissue viability research and 2012REUTERS
20
JOUR
information. JWC is essential reading for IMPACT FACTOR
13
all specialists who wish to enhance their
practice and stay ahead of developments 1.906 CI
IO N REP
TAT © O
WC
L
THOMSON
R
C
NA
TS
REUTERS
2012
20
JOUR
in wound management and tissue viability.
IMPACT FACTOR
13
©
H 1.906
O S
T ER
©
H S
MS
O
T
ER
ON REUT
MS
ON REUT
The journal is internationally renowned for journal of wound care

its cutting edge and state-of-the-art research
?? ?? ?
volume 23. number 1. january 2014
and clinical articles, as well as its coverage of

management, education and novel therapies.
JWC has been associated with an Impact

Factor (IF) of 1.906 for 2012, corresponding
to a total number of citations of 1327.
The journal is indexed on Medline, Scopus,

CINAHL and the Thomson Reuters’ Science
Citation Index-Expanded and Current
Contents/Clinical Medicine
“The Journal of Wound Care is an

extremely valuable resource that
contains a wealth of peer-reviewed
papers detailing the latest advances in NPWT for sternal wound infections following
wound care research. A must read for congenital heart surgery
clinicians, academics and researchers W.A.R. scores in patients with chronic leg ulcers: results of a multicentre study
Evaluating the reasons underlying treatment nonadherence in VLU patients: Part 1 of 2
who want to advance their own Venous leg ulcers: What about well-being?
knowledge/practice and keep abreast Physiological and appearance characteristics of skin maceration in elderly women
with incontinence
of the wound care literature.”
JWC_23_01_Cover.indd 1 02/01/2014 14:25
Caroline McIntosh, Head of Podiatry,

National University of Ireland
SUBSCRIBE TODAY
Obtain access to the online archive containing all content
published in JWC since 1999 with an online subscription†.
†Online archive accessible only via a online only OR print and online subscription.
Visit: www.magsubscriptions.com/jwc
or call us on: +44 (0) 1722 716 997
Join us for debate and discussion: Journal of Wound Care
AAWC

Managing Wounds As A Team: Exploring The Concept of A Team Approach To Wound Care

Uploaded by

Copyright:

Available Formats

Managing Wounds As A Team: Exploring The Concept of A Team Approach To Wound Care

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Managing Wounds As A Team: Exploring The Concept of A Team Approach To Wound Care

Uploaded by

Copyright:

Available Formats

Exploring the

A joint position document

Editorial support and coordination: EWMA Secretariat

Corresponding author: Editor, Professor Zena Moore [email protected]

This article has not undergone double-blind peer review;

Published on behalf of EWMA by MA Healthcare Ltd.

The problem of wounds  7

Clinical evidence for managing wounds as a team  11

Barriers & facilitators  19

Universal model for the team approach to wound care  26

Summary and conclusion  32

Definition of commonly Fundamentally, the central issue is that the group

Therefore, the reason why the term “team” is • Wound Type

Introduction to reach consensus on 76 included publications.

Professional Organisation / Guidelines on Wound Care Recommend

The ‘will’ of participating It is evident that if future graduates are to

Established hierarchical structures that perceive

Me Team Health service organisations based on the political

Recent innovations in telecommunication Support

Organisational/financial benefits have been • Education about how to function within a

Multidisciplinary teams can be created from • Communication systems including

model that is focused on patient perceived needs

professionals. Wound navigators could be formal m Wound

roles created within the wound team similar

to case management models used in palliative

care and mental health services.156-158 This would profe h

navigator and enable the collection of patient Patient

first health professional approached by the patient.

Whilst this would require additional education

Physical needs Physical needs

• Tissue • Rehabilitation services

Psycho social needs Psycho social needs

The journal is internationally renowned for journal of wound care

and clinical articles, as well as its coverage of

JWC has been associated with an Impact

The journal is indexed on Medline, Scopus,

“The Journal of Wound Care is an

Caroline McIntosh, Head of Podiatry,

You might also like

The problem of wounds 7

Clinical evidence for managing wounds as a team 11

Barriers & facilitators 19

Universal model for the team approach to wound care 26

Summary and conclusion 32