Employing interdisciplinary team working to improve patient ... - EWMA
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Presented at<br />
<strong>EWMA</strong> 2011<br />
Brussels · Belgium<br />
Developing evidence-based ways of <strong>working</strong>:<br />
Science, Practice and Education<br />
<strong>Employing</strong> <strong>interdisciplinary</strong> <strong>team</strong><br />
<strong>working</strong> <strong>to</strong> <strong>improve</strong> <strong>patient</strong> outcomes in<br />
diabetic foot ulceration – our experience<br />
1. HISTORY AND INTRODUCTION<br />
The treatment of wounds is an ancient area of<br />
“specialization in medical practice”. Its origins<br />
trace <strong>to</strong> ancient Egypt and Greece. The most profound<br />
advances in the field came with the development<br />
of microbiology and cellular pathology<br />
in the 19 th century. In the 1870s, R.W Johnson,<br />
the cofounder of Johnson & Johnson, began the<br />
production of gauze and wound dressings with<br />
Iodine. In the late 19 th century P.L. Friedrich<br />
introduced the importance of wound excision, a<br />
procedure that reduced the risk of infection and<br />
thus surgery was on board….<br />
The diabetic clinic at the Deaconess Hospital in<br />
Bos<strong>to</strong>n can be considered as one of the first <strong>to</strong><br />
instigate a multidisciplinary approach in diabetic<br />
wound care, bear in mind that the discovery of<br />
insulin was still a few years ahead! The teaching<br />
of diabetic foot care was considered so important<br />
that by 1928 they had assigned one graduate nurse<br />
and two pupil nurses <strong>to</strong> that duty. 1<br />
From the moment we use the term “specialization<br />
in different fields of wound care” we are<br />
already speaking about multidisciplinarity.<br />
2. DEFINITION OF A<br />
MULTIDISCIPLINARY TEAM<br />
We have found some different explanations/definitions<br />
of a multidisciplinary <strong>team</strong>:<br />
“…A group of people with different kinds of<br />
training and experience <strong>working</strong> <strong>to</strong>gether, usually<br />
on an ongoing basis. Professionals often use the<br />
word “discipline” <strong>to</strong> mean a field of study such<br />
as medicine, social work, or education…” (www.<br />
dwp.gov.uk department for work and pensions).<br />
“A group composed of members with varied<br />
but complementary experience, qualifications,<br />
and skills that contribute <strong>to</strong> the achievement of<br />
the organization’s specific objectives” (Oxford<br />
Dictionary).<br />
“A multidisciplinary <strong>team</strong> is composed of<br />
members from different healthcare professions<br />
with specialized skills and expertise. The members<br />
coordinate and communicate with each other <strong>to</strong><br />
provide quality <strong>patient</strong> care. Coordination and<br />
<strong>team</strong>work among clinicians results in greater efficiency<br />
and <strong>improve</strong>d clinical outcomes” (Journal<br />
of Healthcare Quality, March/April 2004). 2<br />
In our further work we try <strong>to</strong> clarify why the use<br />
of some words will play a major role and why<br />
perhaps the terminology of multidisciplinarity is<br />
not our favourite in our context of <strong>team</strong>s concerning<br />
wound care.<br />
3. WHY WE SHOULD USE<br />
INTERDISCIPLINARY IN THE CONTEXT<br />
OF WOUND CARE?<br />
A two-step approach<br />
a. Difference between professionals and<br />
disciplines.<br />
We are privileged that an expert as respected as<br />
Paul Gorman wrote several articles and books<br />
about multidisciplinary <strong>team</strong>s. He helped us <strong>to</strong><br />
understand the differences and nuances between<br />
professionals and disciplines. 3<br />
It’s fascinating <strong>to</strong> question why we have developed<br />
different disciplines in medicine. As human<br />
beings we have learnt that specialization enables<br />
us <strong>to</strong> know more about things. Receiving greater<br />
depth of knowledge will give us greater control<br />
over that part of our world and our environment.<br />
At the same time, other people have specialist<br />
knowledge about other things. Coming <strong>to</strong>gether<br />
we will have an even greater area of knowledge.<br />
Knowledge, but also status, reward and power, are<br />
divided by the boundaries of professions and disciplines.<br />
To demonstrate this Paul Gorman gave<br />
us the following examples: doc<strong>to</strong>rs get paid better<br />
than nurses and in some environments, have more<br />
status and power. Gender <strong>to</strong>o plays a crucial role<br />
<br />
Kristien Van Acker<br />
Diabe<strong>to</strong>logist, Md, PhD<br />
Chimay, Rumst,<br />
Vice Chair DFP, IDF,<br />
Consultant Trop Inst<br />
Antwerp, Belgium<br />
Correspondence:<br />
stiebertje.viroin@<br />
gmail.com<br />
Conflict of interest: none<br />
<strong>EWMA</strong> JOURNAL 2012 VOL 12 NO 2 31
in the way professions operate internally and the way they<br />
interact with each other. This lead <strong>to</strong> defining the mission<br />
statements of the professional bodies (e.g. podiatry,<br />
chiropody and nursing); in his<strong>to</strong>ry we see the development<br />
of professional bodies, acting as gatekeepers <strong>to</strong> the professions.<br />
Those bodies control the right <strong>to</strong> practice and will<br />
protect the public from charlatans, and this can only be<br />
seen as an advantage. However an individual, namely a <strong>patient</strong>,<br />
is not approached on a daily basis by the professional<br />
bodies but by medical <strong>team</strong>s. For this reason, it’s preferable<br />
<strong>to</strong> speak in terms of multidisciplinary <strong>team</strong>s (MTs) instead<br />
of multi-professional <strong>team</strong>s. In MTs members of staff, like<br />
auxiliaries, receptionists, and all the others also have a<br />
central role. Another important point is that the <strong>patient</strong>s<br />
and their relatives have also a central place, which is not<br />
in the case in a multi- professional <strong>team</strong>.<br />
b. Difference between multidisciplinary (MTs) and<br />
<strong>interdisciplinary</strong> <strong>team</strong>s (ITs)<br />
In 2007 Rebecca L Jessup from Australia was one of the<br />
first <strong>to</strong> adopt the concept of <strong>interdisciplinary</strong> <strong>team</strong>s and<br />
their skills and behavior 4 .<br />
According <strong>to</strong> Paul Gorman, MTs utilize the skills<br />
and experience of individuals from different disciplines,<br />
with each discipline approaching the <strong>patient</strong> from its own<br />
perspective. More often than not, this approach involves<br />
separate individual consultations. These may occur in a<br />
“one-s<strong>to</strong>p-shop” fashion with all consultations occurring<br />
as part of a single appointment on a single day. It is common<br />
for this <strong>team</strong> <strong>to</strong> meet regularly, in the absence of the<br />
<strong>patient</strong>, <strong>to</strong> “case conference” findings and discuss future<br />
directions for the <strong>patient</strong>’s care. MTs provide more knowledge<br />
and experience than disciplines operating in isolation.<br />
ITs, however, integrate separate discipline approaches<br />
in<strong>to</strong> a single consultation, i.e. the <strong>patient</strong>-his<strong>to</strong>ry taking.<br />
The <strong>team</strong>, <strong>to</strong>gether with the <strong>patient</strong>, conducts assessment,<br />
diagnosis, intervention and short- and long-term management<br />
goals at the one time. The <strong>patient</strong> is intimately<br />
involved in any discussions regarding their condition or<br />
prognosis and the plans about their care. Individuals from<br />
different disciplines, as well as the <strong>patient</strong> themselves, are<br />
encouraged <strong>to</strong> question each other and explore alternate<br />
avenues, stepping out of discipline silos <strong>to</strong> work <strong>to</strong>ward<br />
the best outcome for the <strong>patient</strong>. In these processes, family<br />
members and partners will also be involved in the plans<br />
about the care of their family member. Those who have<br />
experience in this approach will immediately recognize a<br />
personal expression: “<strong>working</strong> in the order of chaos!” The<br />
energy and general demands are huge but the rewards are<br />
great, and perhaps the most important benefit is the richness<br />
of the contacts of <strong>team</strong> members with the <strong>patient</strong>s<br />
and their family with, in return, the confidence the <strong>patient</strong><br />
gives back even when prognosis is poor.<br />
32<br />
4. WHAT CAN BE CONSIDERED AS<br />
“PRACTICAL” GOLDEN RULES<br />
For <strong>team</strong>building and <strong>working</strong> in an <strong>interdisciplinary</strong><br />
<strong>team</strong>? 5-9<br />
No-one anywhere can start such an Interdisciplinary Team<br />
Project without a respectable time of preparation and a<br />
clear concept of the project management in which he/she<br />
has <strong>to</strong> take at least four characteristics in<strong>to</strong> account: definite<br />
duration, examine the logic relationship with other<br />
activities in the project, study the resource consumption<br />
of this <strong>team</strong> (information, energy, know how, time and<br />
financial resources) <strong>to</strong>gether with the associated costs. This<br />
means that at the very least, for long-term success, a person<br />
must develop a business plan and management skills.<br />
The initiative taker will define roles and boundaries.<br />
Everyone needs clarity on his/her own role and it has <strong>to</strong><br />
be clear <strong>to</strong> each member what other <strong>team</strong> members do.<br />
The <strong>team</strong> coordina<strong>to</strong>r has <strong>to</strong> be aware of power dynamics<br />
within the group, i.e. are certain members competing<br />
for control? Or do some have more status than others?<br />
The process of “taking decisions” must be analyzed on<br />
a constant basis in the <strong>team</strong>; how, who and when is important.<br />
Team members must learn <strong>to</strong> value each other’s<br />
contributions and look at how the group communicates.<br />
In addition, they have <strong>to</strong> be aware that “different professionals<br />
have different views” and that this is the added<br />
value of the concept.<br />
Implementation of feed-back loops for self-evaluation<br />
is helpful in detecting some barriers and is of utmost importance<br />
<strong>to</strong> the success of ensuring members do not underestimate<br />
the value of listening <strong>to</strong> service users (<strong>patient</strong>s).<br />
Often small details are huge barriers <strong>to</strong> <strong>team</strong> success. Some<br />
of the biggest barriers include unclear goals, unhealthy<br />
communication, playing it ‘safe’, individual goals and poor<br />
leadership.<br />
5. INTERDISCIPLINARY TEAMS IN DIABETIC<br />
FOOT WOUND CARE<br />
a. Rationale and evidenced based data<br />
One example of where building an <strong>interdisciplinary</strong> <strong>team</strong><br />
is useful and effective is the diabetic foot <strong>team</strong>. We refer <strong>to</strong><br />
the International Consensus of the Diabetic Foot, audited<br />
by Karel Bakker and first launched in 1996 and the fourth<br />
edition recently launched at the International Diabetic<br />
Foot Meeting in May 2011 in Noordwijkerhout 10 .<br />
In this consensus the following statements can be<br />
found: “If you have a foot problem, you should obtain<br />
foot care from a multidisciplinary foot <strong>team</strong>. A multidisciplinary<br />
approach has been shown <strong>to</strong> bring about a 45-85%<br />
decrease in amputations”. This sounds impressive, so what<br />
are the references and the associated evidence?<br />
The first publication on multidisciplinary diabetic foot<br />
clinics was published in 1986 by Mike Edmonds in which<br />
<strong>EWMA</strong> JOURNAL 2012 VOL 12 NO 2
he illustrated the <strong>improve</strong>d survival of the diabetic foot<br />
and the role of a specialized foot clinic. 11 In 2005 Lavery<br />
LA published the outcome of a study of 2738 persons<br />
with diabetes carried out over 28 months. Stratification<br />
in<strong>to</strong> low and high-risk groups was performed with the<br />
implementation of preventive or acute care pro<strong>to</strong>cols.<br />
The outcome was impressive: a 47% decrease of the incidence<br />
of amputations; 38% reduction in foot-related<br />
hospital admissions; 22% reduction of average hospital<br />
days and 70% reduction in SNF (skilled nursing facilities)<br />
admissions. 12 This model has been widely replicated; the<br />
group of Gerry Ryman 13 illustrated a significant reduction<br />
in <strong>to</strong>tal and major amputation rates in a defined U.K.<br />
population measured over an 11-year period (1995-2005)<br />
following <strong>improve</strong>ments in foot care services including<br />
multidisciplinary <strong>team</strong>work. Expressed as incidence per<br />
10,000 people with diabetes, <strong>to</strong>tal amputations fell 70%,<br />
from 53.2 <strong>to</strong> 16.0, and major amputations fell 82%, from<br />
36.4 <strong>to</strong> 6.7. This was also the result of a continuous prospective<br />
audit.<br />
b. How <strong>to</strong> establish a diabetic foot clinic<br />
Some years ago, the IWGDF convened a roundtable meeting<br />
<strong>to</strong> discuss the principles of organizing a diabetic foot<br />
clinic. We published these data in the Time <strong>to</strong> Act in the<br />
year of the “Diabetic Foot”, 2005 14 . The idea of the <strong>working</strong><br />
group was <strong>to</strong> make a distinction between three models:<br />
The minimal model or basic model, the intermediate<br />
model, and the centres of excellence also called tertiary<br />
referral centres model. In practice, the gradual process<br />
<strong>to</strong>wards excellence is initiated by a dedicated individual,<br />
a “local champion”, <strong>working</strong> in a very small <strong>team</strong>. More<br />
often than not, this person drives the project for many<br />
years and he or she assumes much of the responsibility<br />
from the start.<br />
Please visit the IWGDF website for more information: www.iwgdf.org<br />
Table 1: The Different Models of Diabetic Foot Care according <strong>to</strong> the IWGDF.<br />
Science, Practice and Education<br />
In Table 1 we present the three models and refer <strong>to</strong><br />
the publication of Time <strong>to</strong> Act for more details. By accepting<br />
the concept of this “Three Level Model”, we are<br />
aware that referral patterns between these levels of care in<br />
this global organization must be clearly defined. This will<br />
only be possible if the organization in the country has a<br />
well-established centre of excellence. Good structures will<br />
have a positive influence on reducing delays in referrals!<br />
c. The importance of feedback loops and benchmarking:<br />
Quality control<br />
Delivery of good diabetic foot care is also dependent on<br />
the need for feedback and self reflection if we are <strong>to</strong> witness<br />
<strong>improve</strong>ments in the performance of the <strong>team</strong>s which in<br />
turn lead <strong>to</strong> <strong>improve</strong>ments in the delivery and outcome<br />
of the medical care 15 . To evaluate the input, or the intervention<br />
(e.g. “multidisciplinary diabetic foot clinic”)<br />
and the process itself we have <strong>to</strong> register the outcome<br />
parameters for our evaluation. There are many examples<br />
of such processes. One of the modern techniques used is<br />
benchmarking.<br />
One of the first important studies <strong>to</strong> compare differences<br />
by centre is the EURODIALE 16-18 . In this study (a<br />
prospective cohort study of 1232 consecutive individuals)<br />
we learned that treatment of many <strong>patient</strong>s is not in line<br />
with current guidelines and there are large differences between<br />
countries and centres. At study entry, 77% of the<br />
<strong>patient</strong>s had inadequate or no offloading. During followup,<br />
casting was used in 35% (0-68% variation between<br />
countries!) of the plantar fore- or midfoot ulcers. Vascular<br />
imaging was performed in 56% (14-86%) of <strong>patient</strong>s with<br />
severe limb ischemia; while revascularization was (only)<br />
performed in 43%.<br />
At the current moment only two countries, namely<br />
Germany and Belgium, are known <strong>to</strong> have this quality<br />
control system. In the disease-management programme<br />
in Germany, providers are obliged <strong>to</strong> refer high-risk feet,<br />
ulceration and suspicion of diabetic osteoarthropathy <strong>to</strong><br />
specialized diabetic foot clinics at predefined interfaces.<br />
Minimal Model Intermediate Model Maximal Model<br />
Staff Doc<strong>to</strong>r/nurse or<br />
podiatrist<br />
Aim Prevention and basic<br />
curative care<br />
Doc<strong>to</strong>r or General Physician<br />
Surgeon<br />
Podiatrist and/Nurse<br />
Orthotist<br />
Prevention and basic curative care for<br />
all types of <strong>patient</strong>s and advanced assessment<br />
and diagnosis<br />
Patients Own <strong>patient</strong>s From the regional catchment area of<br />
the hospital with possibly some referrals<br />
from outside the region<br />
Setting Small regional hospital,<br />
health centres<br />
Diabe<strong>to</strong>logist/surgeon/rehabilitation<br />
specialist/microbiologist/derma<strong>to</strong>logist/<br />
Psychiatrist/nurse/educa<strong>to</strong>r/podiatrist/<br />
casting technician/secretarial staff...<br />
Prevention and specialized curative care<br />
provide training for other centres<br />
National, regional or even international<br />
reference centre<br />
Hospital Reference centre (Third line centre)<br />
<strong>EWMA</strong> JOURNAL 2012 VOL 12 NO 2 33
Science, Practice and Education<br />
An <strong>interdisciplinary</strong> Diabetic Foot Team in action: Order in the Chaos. Diabetic Foot Clinic – Kristien Van Acker<br />
Standards of Quality for Specialized Diabetic Foot Clinics<br />
according <strong>to</strong> the Criteria of the Diabetic Foot Working<br />
Group of the German Diabetes Association (DDG) are<br />
based on Structural quality (equipment, documentation,<br />
and staff); Structural- and Process quality (<strong>interdisciplinary</strong><br />
cooperation by contract); Process quality (clinical<br />
pathways/standard operation procedures (SOP); Hygiene<br />
plans, (MRSA management plan); Audit (active and passive);<br />
and Quality of performance (treatment results of 30<br />
consecutive <strong>patient</strong>s).<br />
In Belgium, some opinion leaders <strong>to</strong>gether with Scientific<br />
Institute of Public Health, Epidemiology in Brussels<br />
developed an “Initiative for Quality of Care Promotion<br />
and Epidemiology in Belgian Diabetic foot clinics”, the socalled<br />
IQED centres. This prospective study is designed <strong>to</strong><br />
describe, evaluate and <strong>improve</strong> the Quality of Care in the<br />
Belgian diabetic foot clinics (DFC) by collecting data and<br />
providing benchmarking. In this study Off-loading was<br />
used in 75% (variation from 42% <strong>to</strong> 100%) of the ulcer<br />
<strong>patient</strong>s, but a <strong>to</strong>tal contact cast was only used in 2.4%.<br />
Of the <strong>patient</strong>s with peripheral arterial disease, 42.8% underwent<br />
revascularization and 59.4% were hospitalized 19 .<br />
34<br />
6. GENERAL CONCLUSIONS AND THE<br />
CONCEPT OF INTERDISCIPLINARY TEAMS<br />
FOR INTEGRATED WOUND CARE<br />
In many countries and societies care facilities have come<br />
a long way in developing their wound care programs,<br />
especially where there is more effort <strong>to</strong>wards an <strong>interdisciplinary</strong><br />
approach. They have moved away from the<br />
approach of just having a single wound treatment nurse<br />
and established a more integrated care approach. The most<br />
successful <strong>team</strong>s are those that have a wound care <strong>team</strong><br />
involving all key departments within the facility. In hospitals<br />
it starts with the medical direc<strong>to</strong>r who facilitates<br />
the necessary <strong>patient</strong> medical work-ups as, for example, a<br />
therapy <strong>to</strong> apply specific services such as modalities and<br />
wound debridement, and dietary services <strong>to</strong> ensure that<br />
those with wounds have adequate nutritional intake. On<br />
the other hand, well skilled home nurses who provide<br />
primary <strong>patient</strong> care including wound dressings are also<br />
important key players. But in this advanced situation the<br />
key pitfall will be a good referral system and communication<br />
between the first, second and tertiary line <strong>team</strong>s.<br />
Ultimately, highly coordinated treatment plans are effective<br />
in reducing average wound healing times, thereby<br />
lessening <strong>patient</strong> suffering and costs of care.<br />
<strong>EWMA</strong> JOURNAL 2012 VOL 12 NO 2
In this philosophy we must consider <strong>to</strong>day integrating<br />
all the different “thematic” <strong>team</strong>s. Personally, I believe in<br />
an integration of <strong>team</strong>s specialized in wound care of diabetic<br />
foot ulcers, pressure ulcers, venous ulcers and others.<br />
This is already the case in some countries, such as the U.S.<br />
Finally, I would like <strong>to</strong> conclude that all worldwideknown<br />
diabetic foot clinics, the so called ‘Centres of<br />
Excellence’, were created one step at a time, beginning<br />
with the basic model. This paper has reported the experience<br />
of building one. This may be of use <strong>to</strong> those clinical<br />
personnel who are considering the effectiveness of their<br />
ways of <strong>working</strong> and the associated <strong>patient</strong> outcomes. We<br />
have reported <strong>improve</strong>d <strong>patient</strong> outcomes following the<br />
implementation of this evidence-based model and would<br />
encourage others <strong>to</strong> consider employing this approach.<br />
‘A journey of a thousand miles begins with one step…’<br />
Lao Tzu, China, 6 th century <br />
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diabetes voetklinieken. (pp. 11-40). Brussels:Wetenschappelijk Instituut Volksgezondheid.<br />
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