Dr. Robert Snyder is a podiatrist with over 30 years of experience; his practice is limited to wound management and limb preservation. He is Professor and Director of Clinical Research and Fellowship Director at Barry University SPM. Dr. Snyder is certified in foot and ankle surgery by the American Board of Podiatric Surgery and is also a board certified wound specialist. Dr. Snyder is immediate past-president of the Association for the Advancement of Wound Care and past-president of the American Board of Wound Management. In addition to his doctorate, he holds an MSc in Wound Healing and Tissue Repair from Cardiff University. Dr. Snyder has published several book chapters over 125 papers in peer reviewed and trade journals on wound care and has been a principal investigator on more than 30 randomized controlled trials.
Snyder_Current Dialogues in Wound Management_2016_Volume 2_Issue 1
A driving force behind health care practitioners’ transition from being soloists to members of any orchestra is the complexity of modern health care.
Patients with chronic or stalled wounds often present with underlying medical problems that stifle the normal healing cascade. These lesions may be as serious as some cancers. Concomitant comorbidities such as diabetes, peripheral arterial disease and hemodialysis are independent markers for protracted or non-healing scenarios. Once an amputation is required, mortality can be as high as 80% within 5 years. Therefore, these individuals require a holistic, patient-centered approach to diagnosis and treatment utilizing a host of medical specialists that function in tandem within a multidisciplinary milieu.
WHAT IS THE MULTIDISCIPLINARY APPROACH?
In broad strokes, Naylor et al2 view team-based healthcare as the provision of health services to accomplish shared goals within and across settings to achieve coordinated, high quality care. Although this concept appears straight forward, there are many variations on this theme, which may ultimately cause the clinician to stray from the basic tenets of this approach.
Both Boone3 and Orchard,4 for example, opine that a multidisciplinary approach purports that team members need only be aware of and share information with other disciplines; however, these professionals often work sequentially (and independently), utilizing the medical record as the chief means of communication, thus suppressing the universal importance of teamwork. Specialists often function in “silos.” Each clinician has a role and often “waits his/her turn” to perform a specific skill set, and direct communication between specialists is often lacking.
WHAT DOES THE EVIDENCE TELL US?
Sadly, this explanation omits the key drivers to multidisciplinarianism: With the increased complexity of health care (i.e. National Guidelines Clearinghouse has over 2,700 Clinical Practice Guidelines (CPGs) and over 25,000 new clinical trials are published per year), no single person can absorb and use all this information. This precept leads to an international imperative for improved quality, safety, cost-effective and patient-centered health care. To this end, the Institute of Medicine has proclaimed that all clinicians have an obligation to practice team-based health care.
In other research, Maklebust6 stated that multidisciplinary specialized wound healing concepts integrated into (a) national health care system…would be the ideal way to organize wound healing to best benefit patients and society.
Furthermore, Gottrup hypothesizes that multidisciplinary wound care teams that conduct rounds at the bedside are highly recommended to enhance patient outcomes.7Seventeen professional organizations promote guidelines that foster the team approach to wound management.8 Together, diabetic foot ulcer (DFU) studies included over 3000 subjects, and all reported positive clinical outcomes after wound care team interventions.9 Sloan et al showed that most centers were based in university or medical center hospitals where grouping of professionals from multiple specialties was more easily accomplished; however, the benefit of a team approach was demonstrated irrespective of setting (i.e.“clinics without walls”).
A multidisciplinary team approach has also been proven to be the most effective means of providing treatment and preventing foot lesions in the diabetic patient. Both Sumpio et al11 and Fryberg12 agree this methodology provides a comprehensive treatment protocol, significantly increases the chances of successful wound healing, and fosters a low rate of recidivism. Cost reduction may be achieved through saving the clinician time, consolidation of services and downstream revenue production.
CAN THIS APPROACH PREVENT AMPUTATION?
The multidisciplinary approach may also decrease amputation rates. In Denmark, for example, this management program integrating vascular intervention and wound care reduced lower extremity amputation (LEA) rates by 75%. Furthermore, Yesil and colleagues decreased major amputation rates from 20.4% to 12.6% with the team approach. Better healing rates may translate to a more efficient use of resources.
The economic benefits could be significant. Research by Vu et al revealed that standardized treatment provided by multidisciplinary wound care teams could lower costs and (even) improve chronic wound healing in nursing homes.
WHAT ARE THE TRENDS IN THE US?
Fortunately, research conducted by an Interprofessional Education Collaborative Expert Panel16 reveals a trend in the US towards patient-centered, relationship-focused, process-oriented, and outcome-driven care including Interprofessional teamwork and IOM Core Competencies. Unfortunately, multidisciplinary education and practice occur when several disciplines work in parallel, often with independent goals. In contrast, interdisciplinary education may include a variety of disciplines from health and other fields of study that collaborate through joint planning, decision-making, and goal-setting.
WHY AN INPATIENT LIMB PRESERVATION TEAM?
What’s changed recently is not so much the fundamental approach as the speed with which it unfolds. Today, hospitals are launching comprehensive interdisciplinary interventions to prevent amputation that are implemented in hours instead of weeks.
A 2010 article in the Journal of Vascular Surgery outlined the basic approach, which includes screening and prevention, wound healing, infection management, and revascularization—and in which the team of diabetic podiatrist and vascular surgeon form the “irreducible minimum.”18 In a study at Madigan Army Medical Center in Tacoma, WA, investigators reported that the implementation of the hospital’s Limb Preservation Service resulted in an 82% decrease in lower extremity amputations over five years, from 9.9 to 1.8 per1000 diabetes patients (actual amputation numbers dropped from 33 to 9, reported from 1999 to 2003). Moreover, this decline took place even as diabetes cases jumped 48%.
In summary, the following quote embodies the holistic approach to medicine in the 21st century:
“The health care we want to provide for the people we serve—safe, high-quality, accessible, person-centered—must be a team effort. No single health profession can achieve this goal alone.”
References
1.Mitchell, M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach and I. Von Kohorn, Core Principles & Values of Effective Team-Based Health Care, Institute of Medicine, 2014. [Online]. Available at: www.iom.edu/tbc.
2. Naylor MD, Sochalski JA. (2010). Scaling Up: Bringing the Transitional Care Model into the Mainstream. The Commonwealth Fund, Issue Brief, November.
3. Boon H, Verhoef M, O’Hara D (2004). From parallel practice to integrative health care: a conceptual framework BMC Health Services Research 2004 4:15. DOI: 10.1186/1472-6963-4-15. Published: 01 July 2004.
4. Moore Z, Butcher G, Snyder R, et al. AAWC, AWMA, EWMA Position Paper: Managing Wounds as a Team. J Wound Care 2014; 23 (5Suppl): S1-S38.
5. Mitchell, M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach and I. Von Kohorn, Core Principles & Values of Effective Team-Based Health Care, Institute of Medicine, 2014. [Online]. Available at: www.iom.edu/tbc.
6. Maklebust J. June 2005 Pressure Ulcers: The Great Insult. Journal- Nursing Clinics of North America Volume 40 Issue 2 (365-389).
7. Gottrup F. Organization of wound healing services: The Danish experience and the importance of surgery. Wound Repair and Regeneration (2003) 11(6): 452-457.
8. Lindholm C, Bergsten A, Berglund E. Chronic wounds and nursing care (1999) Journal Wound Care 8:1, 5-10.
9. Armstrong DG, Harkless LB. Outcomes of preventative care in a diabetic foot specialty clinic. J Foot Ankle Surg 1998; 37(6):460-466.
10. Sloan F, Feinglos M, Grossman D. Receipt of Care and Reduction of Lower Extremity Amputations in a Nationally Representative Sample of U.S. Elderly. Health Serv Res. 2010 Dec; 45(6 Pt 1): 1740–1762.
11. Sumpio BE, Aruny J, Blume PA. The Multidisciplinary Approach to Limb Salvage. Centers for Vascular Disease and Diabetic Limb Preservation, Yale University School of Medicine, New Haven, CT.
12. Frykberg RG. (1998) The team approach to diabetic foot care. Advances Skin Wound Care 11(2): 71-77.
13. Gottrup F, Holstein P, Jørgensen B, et al. A New Concept of a Multidisciplinary Wound Healing Center and a National Expert Function of Wound Healing. Arch Surg. 2001;136(7):765-772. doi:10.1001/archsurg.136.7.765.
14. Yesil S, Akinci B, Bayraktar F. Reduction of major amputations after starting a multidisciplinary diabetic foot care team: single centre experience from Turkey Exp Clin Endocrinol Diabetes. 2009 Jul;117(7):345-9. doi: 10.1055/s-0028-1112149. Epub 2009 Feb 18.
15. Vu T, Harris AH, Duncan G. Cost effectiveness of multidisciplinary wound care management in nursing homes: a pseudo randomized pragmatic cluster trial. Family Practice 2007 24: 372-379.
16. Interprofessional Education Collaborative Expert Panel (2011).
17. World Health Organization (WHO). (2010). Framework for Action on Interprofessional Education & Collaborative Practice. Geneva: World Health.
18. Rogers LC, Andros G, Caporusso J, et al. (2010) Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg. 52(3 Suppl): 23S-27S.
19. Driver VR, Madsen J, Goodman RA. (2005) Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model. Diabetes Care. 28(2): 248-253.
