Streamlining the Management of Patients With Problematic Wounds: Must a Multidisciplinary Team Formulate All Patient Manageme

Background. The Association for the Advancement of Wound Care (AAWC) guidelines promote the comprehensive, interdisciplinary management of patients with chronic wounds by multidisciplinary teams (MDTs) comprised of designated specialists.¹ Since these patients are known to have a high incidence of multiple medical problems, comorbidity factors that require input from many specialties for wound prevention (both effective and safe wound treatment), this approach seems to be logical.² Conversely, since problem wounds should be promptly treated,management systems should reduce or eliminate any redundant time needed for work-up or treatment implementation.^3,4 Simple enhancement of communication between specialist and primary care providers shortens the time needed to implement a management plan. Previous studies demonstrated that although telemedicine based assessment might not replace a face-to-face, comprehensive SWCS assessment of a patient with a chronic wound, telemedicine based judgments are relatively accurate and streamlines the management process.^4,5 With consideration of morbidity that results from delayed wound care program implementation, costs, emotionally and physically stressful transportation, available resources within care settings, and the development of pressure sores—decreasing management plan implementation time seems feasible. This can be accomplished through providing necessary evidence that would establish the value of evidence based MDT decision-making and its impact on the initial (SWCS) assessment and management plan.⁶ Specifically, this study was undertaken to determine the impact of MDT meetings with respect to changes in the management plan of problematic wounds already formulated by a SWCS after review of electronically-transmitted data and direct patient examination.

Methods
The study population included 124 patients with problematic, nonhealing wounds, newly referred to the Wound Care Program and Surgical Consultant by their primary care physician. These patients were seen from January 2005 through December 2006 for telemedicine consultations followed by a direct examination by a surgical specialist (in this the senior author is a Board Certified Plastic Surgeon) within 2 weeks from the initial telemedicine consult. The Wound Care Program nurse (RN or LVN) assessed the referred patients within 24 h and obtained digital wound photographs. Once the consultation request was received, an appointment with the surgeon was made. The result of telemedicine consultation was based on e-mailed information and had no bearing on the timing of the direct examination in the wound care clinic. Patients ranged in age 30 to 88 years (mean 64 years) and were residents of southern California longterm care facilities or skilled nursing facilities. There were 73 (59%) men, aged 30 to 82 years (mean 61 years), and 51 (41%) women, aged 32 to 88 years, (mean 67 years). The majority (> 90 %) of patients were in poor health and life-functional status as defined by the presence of at least 2 of 4 health-related quality of life domains. These domains are: 1) poor physical function with inability to ambulate and complete activities of daily living, 2) lack of psychological well-being with a decreased level of alertness, presence of depression, anxiety or fear, 3) impaired somatic, and 4) social functioning.^7,8 Problem wounds were defined as those that did not heal for at least 6 weeks since the date of injury or wound diagnosis and commencement of the initial treatment (not under the auspices of the Wound Care Program).³ The epidemiology of conditions with which patients were referred is shown in Table 1.

After each patient’s referral to the Program, the “field wound care nurse” visited the patient, obtained their history, assessed the wound, and obtained digital photographs of the wound and the involved body part. Summarized history, results of laboratory studies (if any), and photographs were transmitted to the SWCS. The SWCS discussed with the nurse, and subsequently with the referring physician, the patient management plan up until the time of the visit with the surgeon. During the face-to-face consultation the patient was reassessed. The initial assessment and management plan (IMP) was developed for implementation until the time of patient presentation to the MDT (consisting of the aforementioned “field” nurse and SWCS, an internal medicine specialist, vascular surgeon, podiatrist, physical therapist, nutritionist, and a social worker) for the review of individual cases formulating the FMP. The IMP included specifics of conservative management (laboratory tests, including arterial and venous Doppler study, other consultations, topical treatment) and proposed surgical intervention (biopsy, debridement, flap or skin graft surgery, repair with a single or multistage approach), and lastly whether SWCS thought this had a significant probability to be changed by the MDT.
An independent investigator judged the agreement levels between the two assessments (IMP by SWCS versus FMP by MDT). Agreement rates were as follows: total agreement,trivial disagreement (not changing the overall management plan (eg, addition of an invasive test such as biopsy or arteriogram, or change from conservative management to surgical intervention), or clinically important disagreement (change of approach).⁹

Results

The IMP was developed for 124 patients with problematic, nonhealing wounds following a “field” evaluation by the Wound Care Program Nurse, telemedicine, and face-to-face consult with a SWCS. Subsequently, the MDT evaluated the patients in a hospital-based wound care center. Surgical intervention (eg, wound debridement, closure with a skin graft, skin flap,or myocutaneous flap) was recommended in 47 (38%) of these patients in the IMP. In 12 cases, IMPs were designated as those “with high potential for a change”(Table 2). However, in 3 cases the FMP developed during the MDT consultation, differed (clinically important difference) changing from conservative to surgical, or from surgical to conservative (2.4%) from the IMP. In 5 cases the assessment changed while the management plan did not. An additional invasive work-up study was required (trivial disagreement, 4.0%). The SWCS identified possible “change cases”(cases with clinically important and trivial changes) before the MDT meetings (Table 2).

Discussion
Although the knowledge that a panel of specialists discussed every problem wound case is reassuring to patients, their families, and referring clinicians—perhaps patients will increasingly expect this to occur in the future—the potential efficacy of the SWCS-based primary assessment and management plan cannot be ignored.^5,10 It appears that the vast majority of newly referred patients with problem wounds do not require discussion at an MDT meeting. Those patients who might benefit (potential for a management plan change) can be identified by a SWCS in advance. While it may be the case that a more expanded study would have revealed more pertinent management changes and identified cases of care compromise resulting from the absence of the MDT input, it becomes apparent that the MDT discussion of every case is not justified. Multidisciplinary team management is a fundamental pillar to help improve outcomes for patients who are at-risk or have problematic chronic wounds.^1,11,12 The present study demonstrates that SWCS is capable of identifying cases that require discussion with other MDT members. The relatively small number (< 3%) of clinically important disagreements and management changes may allow recognition in that adopting a targeted approach, one could save resources without producing an adverse effect on patient care— provided that all problematic wound management decisions continue to be brought to the attention of a single consultant with appropriate expertise.^5,10,13 The low rate of change may suggest that an experienced SWCS is capable of making wound management decisions without the MDT, but also may be cited as a measure of success for MDT cooperation—an advantage that would not be lost.
It is necessary to address who will have the best expertise to develop a management plan without a MDT for these complex patients with problematic wounds. Do the benefits of management streamlining outweigh the benefits of MDT involvement if the management is based solely on wound nurse and SWCS judgment?^4,5,10 Even if one agrees that selective MDT involvement into the management of patients with problematic wounds ensures acceptable outcomes, almost certainly no one would question that wound care prevention invariably requires collective input of all wound care MDT specialties.^4,11,12

Conclusion
As discussed elsewhere,⁵ the telemedicine-based assessment will not replace a face-to-face, comprehensive SWCS assessment of a patient with a chronic wound. However, since a telemedicine consult as a preliminary management step is safe and relatively free of medical errors, it appears worthwhile to investigate not only appropriate clinical indications to limit patient work-up at the direct SWCS consultation, but also at the telemedicine consultation.⁵