Description of the condition
A pressure ulcer is defined as a localised injury to the skin or underlying tissue, or both, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers, the significance of which have yet to be elucidated (EPUAP/NPUAP 2009). Pressure ulcers are commonly classified according to the depth of tissue damage, ranging from non-blanching erythema of intact skin (tissue redness that does not turn white when pressed) to full-scale tissue destruction (EPUAP/NPUAP 2009).
A large number of risk factors may contribute to pressure ulcer development (Moore 2008), and in keeping with the EPUAP/NPUAP 2009 guidance, Coleman 2013 argues that a complex interplay of these factors increases the probability of pressure ulcer development. There are three primary risk factors of particular significance, namely; mobility and activity; impaired perfusion (circulation problems, possibly due to diabetes); and fragile skin or existing or previous pressure ulcers (Coleman 2013). These risk factors mean that certain populations, such as the very old and those with an inability to reposition themselves freely, are at greater risk of developing pressure ulcers (Moore 2012).
'Prevalence' refers to the number of people with a pressure ulcer at a point in time, or during a specific time period, while 'incidence' concerns the rate at which new pressure ulcers develop in a defined population in a specific time period (Beaglehole 1993). Prevalence and incidence studies indicate that pressure ulcers are common. Indeed, prevalence rates range from 0.38% to 53.2% (Capon 2007; Igarashi 2013; Keelaghan 2008; Kwong 2011; Lahmann 2006; Moore 2012; Moore 2013b; Stevenson 2013; Tubaishat 2010; Vanderwee 2007), and incidence rates vary from 1.9% to 71.6% across Europe, Japan, China, the Middle East, the United States of America (USA), Australia and Canada (Defloor 2005; Igarashi 2013; Jolley 2004; Kwong 2011; Moore 2011; Moore 2013b; Scott 2006). Mean prevalence has been reported as being 20.9% within the acute-care setting, and 11.7% within the long-stay setting; among hospice patients the mean figure is reported to be 35.7%, but drops to 0.04% to 4% for those nursed in the community (Moore 2013b). Incidence figures among the different care settings are similar to prevalence figures. For example, mean incidence of pressure ulcers in the acute-care setting has been reported as being 18% and for the long-stay setting the figure is 6.6%. There is little information available about pressure ulcer incidence within the community-care setting (Moore 2013b).
The impact of pressure ulcers on the individual is profound, spanning the physical, emotional and social domains of life (Gorecki 2009). This impact is largely influenced by factors related to the individual themselves, the healthcare professional and the environment of care delivery (Gorecki 2012). Fundamentally, those living with pressure ulcers experience significant anxieties that relate to their experiences of the ulcer, for example, the presence of unrelieved intractable pain, in addition to challenges to their ability to cope with the demands that treatments impose upon them (Gorecki 2012).
From a European perspective, pressure ulcer management absorbs between 4% and 5% of the annual healthcare budget, with nurse or healthcare-assistant time accounting for up to 90% of the overall costs (Posnett 2009). In the USA, pressure ulcers cost between USD 9.1 billion to USD 11.6 billion per year (EUR 6.7 billion to EUR 8.5 billion), with estimates in 2007, that each pressure ulcer adds USD 43,180 (EUR 31,580) in costs to a hospital stay (Agency for Healthcare Research and Quality 2011). Within the acute care setting in Australia in 2005, median opportunity costs for pressure ulcers were estimated at AUD 285 million (EUR 202 million) (Graves 2005). The human and economic drain on healthcare systems is compounded by the fact that healthcare professionals and clinicians are often not trained in prevention and treatment of pressure ulcers, or remain in systems where multidisciplinary and integrated care processes are not in place, or both (Moore 2013a). Indeed, a higher incidence and prevalence of pressure ulcers has been noted in settings where there are poor organisational strategies for preventing and managing pressure ulcers (Igarashi 2013).
Description of the intervention
Since the late 1990s there have been reports of the impact that multidisciplinary wound care teams can have on pressure ulcer prevention and management in clinical practice (Doan-Johnson 1998; Dolynchuk 2000; Granick 1998). During this era, it was noted that there was an increasing number of formal and informal multidisciplinary wound care teams that adhered to specific patient-care protocols (Doan-Johnson 1998).
Once the best available evidence on the most appropriate way to improve patients' wound-related outcomes had been synthesised and integrated with expert opinion, multidisciplinary wound care teams were created in many settings through the consensus of healthcare professionals with an interest in wound care (Dolynchuk 2000; Gottrup 2003; Haworth 2009). Thus, multidisciplinary wound care teams were created to focus on delivering high quality, holistic and patient-specific skin care to improve patients’ wound-related outcomes and to prevent the deterioration of the integrity of patients' tissue (Dolynchuk 2000; Gottrup 2003; Haworth 2009).
The exact composition of the multidisciplinary wound care team is mainly determined by the patient’s needs, thus, potentially, any healthcare professional can be a member if it is in the patient’s best interest (Gottrup 2004; Clark 2007; Zulkowski 2007; Haworth 2009). It is evident, therefore, that multidisciplinary wound care teams can consist of different healthcare professionals. Teams' key roles include overseeing the pressure ulcer-related education of staff, patients and carers; undertaking pressure ulcer-related research; and supervising the patient’s pressure ulcer prevention and management strategies (Dolynchuk 2000; Gottrup 2004; Ryan 2003; Woo 2008).
While a number of different approaches to the formation of multidisciplinary wound care teams have been reported in clinical practice, they are all said to have had a positive impact on the wound prevention and management care that patients receive (Gottrup 2003; Gottrup 2004; Haworth 2009). Indeed, in one hospital, the multidisciplinary wound care team was found to have reduced the prevalence of pressure ulcers by 18% over three years, and in a different hospital the team was reported to have reduced the pressure ulcer prevalence by 15% in one year (Granick 1998). In another setting, the multidisciplinary wound care team was reported to achieve a high rate of wound healing as 68% of 103 patients with chronic wounds achieved complete or almost complete wound healing, and only 2% of the patients had the recurrence of an old wound (Donnelly 2000). However, the studies referred to here lack the rigor required to clearly determine the impact of the introduction of the multidisciplinary wound care team, because they use a pre-post test design with significant time gaps between the pre and post test, and outcome data were collected using an audit methodology.
How the intervention might work
The intervention in this review is the wound care team: this review will consider the impact that these teams have on pressure ulcer prevention and management. We define the wound care team as a formally-constituted team of healthcare professionals who work closely to supervise the pressure ulcer prevention and management care of people in hospitals or the community-care setting, or both. The team may be multidisciplinary (e.g. any combination of dietician, nurse, medical doctor, physiotherapist, occupational therapist) or uni-disciplinary (e.g. team composed entirely of nurses). The team may focus on a simple strategy (e.g. a turning only regime) or a complex strategy (e.g. dietary, mobilisation, education).
The World Health Organisation (WHO) argues that collaborative practice strengthens healthcare systems and improves health outcomes (WHO 2010). Furthermore, WHO suggests that such an approach to care delivery is key to optimising individual patient outcomes (WHO 2010), thereby enhancing overall health and social gain. Indeed, a lack of integrated care systems and functioning multidisciplinary teams compounds the suffering of patients and increases demands on already overstretched health budgets (Moore 2005). Conversely, structured multidisciplinary interventions, such as interdisciplinary collaboration and education, improve patient outcomes and overall health service delivery (Apelqvist 2000).
The multidisciplinary wound care team is expected to deliver better outcomes compared to the alternative, where a patient's pressure ulcer prevention and management-related care is delivered by one group of healthcare professionals, without the insight, expertise and active participation of fellow healthcare professionals. There are a number of factors that can contribute to the formation of pressure ulcers, or can affect the healing of pressure ulcers, which are perhaps best addressed by pooling the expertise of different healthcare professionals in order to enhance patient pressure ulcer prevention and management-related outcomes. Thus, the multidisciplinary wound care team may have a positive impact on these outcomes because it brings together a range of healthcare professionals with different expertise in order to plan and deliver care to prevent and manage pressure ulcers in a holistic way that is designed to suit the patient’s individual needs.
Why it is important to do this review
International guidelines suggest that to prevent and manage pressure ulcers successfully a team approach is required (Agency for Healthcare Research and Quality 2011; EPUAP/NPUAP 2009). Furthermore, a team approach to care delivery is advocated by WHO (WHO 2010). Although there have been many reports about the positive impact that wound care teams have had on pressure ulcer prevention and management, many of these reports appear to have been underpinned by anecdotal evidence, or have been subjected to little critical scrutiny, so overall, the precise impact of wound care teams is unclear. Therefore, it is important to search and appraise the literature systematically in order to determine the impact of teams on the prevention and management of pressure ulcers. The outcomes of this review will provide clinical decision-makers with the evidence they need to determine whether investment in such teams is of value.