An interdisciplinary approach to wound care can yield rapid and accurate assessments of wounds, promoting optimal healing and reducing the financial strain on patients and the healthcare system.

T

he first recorded wound caregivers were the early Egyptians and Greeks.¹ Much of the philosophy of the village wound care practitioners at that time was based on trial and error with the use of readily available items. There was 1 person known as “the healer.” The science of wound care has advanced in the modern day through research and evidence-based medicine. Specific manipulation of the wound environment is now essential to obtain efficient healing. Modern healers also know that there is more to wound healing than just local treatment of a wound. Wound care has become “wound management” due to the multifactorial complexities involved with the wound patient. In today’s healthcare arena, caregivers also face complicated reimbursement issues, increasing healthcare costs, and an ever-increasing aged population escalating the incidence of wounds. Therefore, caregivers cannot merely care for a wound based only on their preferred methods and level of expertise, local lore, or anecdotal evidence. It takes an entire team to heal a wound. There is a greater importance for wound clinicians today to have a systematic approach to wound management not only to optimize the efficacy of wound care but also to keep the costs down.
       Today, healthcare professionals understand that the cause of wounds, acute and chronic, is multifaceted and often complex. Healing these wounds requires an aggressive, efficient, interdisciplinary approach. Picture the interdisciplinary approach to wound care as a wheel with the wound patient and his or her significant others being the axis or center (see Figure 1). Each spoke of the wheel represents a discipline connected to the patient yet still supports the wheel to allow it to move forward.

Figure 1

The primary interdisciplinary wound care team must consist of healthcare workers and physicians who have had advanced training in wound management. All participants must understand the complexities and the stresses that the patient, family members, and wound clinicians experience with nonhealing wounds.
       The wound care specialist must know how to manipulate the wound environment for quicker healing, must be familiar with pain and infection control, and must be acutely aware of the needs of the patient’s physical, psychosocial, and physiological state. Nurses have traditionally been on the front lines of wound management. As more disciplines emerge as partakers in the management of the wound patient, however, a holistic team approach proves to be more desirable. This method can prove more cost effective due to quicker healing rates and an increased ability to move the patients back to improved or normal activities of daily living (ADLs).

Evidence

       When exploring the disciplines and specialties that comprise the interdisciplinary wound care team, it is important to consider who the players are and what their chief roles involve. Although each discipline has its own unique focus toward wound healing, integration of these skills will promote the best patient outcome. Qualitative and quantitative research demonstrating positive outcomes and the value of comprehensive, multidisciplinary wound care abounds. For instance, in a 3-year acute care hospital project, the multidisciplinary wound care team’s interventions successfully decreased the admission rate of patients with pressure, venous, arterial, and diabetic foot ulcers from 95% to less than 5% while improving healing outcomes, quality of life, mobility, and reducing pain.² In long-term care, a decentralized, multidisciplinary approach to wound care has been effective in reducing the incidence and prevalence of pressure ulcers in geriatric patients.^3,4 In the clinic, a multidisciplinary wound care team eliminated duplication of services, enhanced patient compliance, and increased patient satisfaction and success.⁵

Skilled Nursing

       As mentioned previously, nurses, including registered nurses, licensed practical nurses, and enterostomal therapists (ET) or wound, ostomy and continence nurses (WOCNs), have been on the forefront of wound management. As part of the interdisciplinary team, the nurse can provide skilled wound care and can administer and monitor intravenous (IV) antibiotics, hydration, or parenteral nutrition therapies and provide offloading, compression, and pressure redistribution in the form of support surfaces. The certified wound specialist (CWS), ET, or WOCN provides expertise with issues related to wounds, fistulas, ostomies, skin care, and continence. In addition to medication and local wound management, the nurse will also educate and instruct the patient, family, and staff on disease processes and care issues. Protocol development often is the nurse’s responsibility as well. The nurse works as the liaison to communication among patient, staff, family members, and physicians. He or she also provides continuity of care in the acute, long-term, and home care settings, proceeding with the orders and plans initiated by the physician and/or the wound clinic team.
       Especially in home care, the case manager, often a nurse, acts as a liaison to the team, organizing efforts, procuring supplies and devices, and working with wound care manufacturers and distributors to get patients the gear that they need.

Physical Therapy

       The focus of physical therapists and physical therapy assistants is to restore and promote the wound patient’s optimal strength and physical function. Repeatedly, long-term wound care and offloading of extremity wounds have debilitated wound patients, causing weakness and imbalance. Often, these patients are restricted to beds or wheelchairs and require restorative therapy or surface management to avoid the deleterious effects of surface-induced pressure ulcers. The physical therapist is key in establishing proper wheelchair, cushion, and prosthesis success. The physical therapist can manage specialty clinics for these patients to improve mobility safety and decrease the risk of potential sequelae of improper surface or fit. As the physical therapist works to identify potential or existing problems and to reduce these risk factors for wound development, he or she also works to restore, maintain, and promote physical function using various modalities to stimulate wound healing. Physical therapists also often debride necrotic tissue and apply effective wound dressings to promote healing. The physical therapist devises plans to manage pain issues, promote safety for the patient with transfers and offloading issues, and educate the patient and family members. They may additionally have CWS certification.

Occupational Therapy

       As part of the wound team, occupational therapists often focus on splinting, upper-extremity contracture management, and reduced upper-body strength, which commonly occur in chronic wound patients. Increasing endurance and fine-motor coordination, which are frequently compromised or lost in the long-term care of wound patients, is also emphasized. Improvement in these areas can bolster the patient’s ability to maintain nutrition and hydration, thus improving his or her overall status. The occupational therapist, in conjunction with the physical therapist, can address seating and positioning requirements to enhance the care of wounds. Occupational therapists are trained in psychosocial disorders, which can play an important role in dealing with a patient’s body image issues as well.

Speech Therapists

       Although not associated with direct wound care, the skills of a speech therapist are crucial when the patient’s swallowing ability is impaired and mode of nutrition becomes an issue. To ensure proper wound healing, adequate nutrition—especially protein—is an absolute necessity. Speech therapists can work as part of the team to improve swallowing and oral functions for feeding. In certain situations, a speech therapist may recommend a nasogastric (NG) tube or enteral feeding mechanism. Also, this team member can improve the patient’s ability to communicate, allowing the patient to better communicate pain levels, positioning comfort, and other basic needs.

Nutritionist/Registered Dietitians

       A registered dietitian is important in developing instructions for patients and family members regarding nutrition necessary to heal wounds and maintain physiological function and overall well being. The patient who is malnourished, has a chronic nonhealing wound, or has diabetes requires a specific diet designed to improve the healing process, provide key nutrients, and offset the increased caloric demands that a healing wound presents.

Medical Social Worker

       The social worker’s role is important in that he or she can evaluate the social and environmental factors affecting the wound patient and his or her family/significant others or caregivers. The social worker, along with a chaplain service or spiritual counselor, provides necessary emotional and psychosocial support. This can increase positive outcomes for wound healing by reassuring the patient that community resources are available and that there are means in place that reduce the financial and emotional burdens the patient and his or her family must bear. Reducing this stressful impact can alleviate the patient’s and family caregiver’s concerns and allow focus on healing.

Physician and Specialist Care

       A cohesive interdisciplinary approach frequently begins with the primary care physician, internist, or specialty physician disciplines. There are several specialties that are predominant in wound care circles, and customarily, they are directly involved in a wound care clinic or long-term care practice. If the primary care physician does not possess advanced wound care management training, he or she must be diligent to refer the patient to a physician wound specialist who does. The physician wound specialist, in turn, must have a plan to alleviate the underlying causes as well as treat the wound with a patient-centered focus. This concentration frequently requires cross-referral among specialists.
       These specialists may include a dermatologist, vascular or general surgeon, podiatrist, plastic surgeon, or orthopedic surgeon. Routinely, this wound specialist is a leader in wound management who relies initially on his or her specific area of expertise while interconnecting its relationship to wound healing. Any of these specialties can complement and augment the healing of the wound patient. A secondary referral pattern may be required by any of these primary wound specialists at any time during the wound care scenario. A consult with a number of specialties may be appropriate. These specialists may include an endocrinologist/diabetologist, infectious diseases specialist, gerontologist, pathologist/dermatopathologist, algologist or pain management specialist, radiologist, hyperbaric specialist, pharmacist, pedorthotist/orthotist, or a manual lymphatic drainage therapist.
       If a patient’s wound care requires additional surgical intervention outside the physician’s scope of expertise in wound management, he or she should refer and coordinate care with other surgical specialties within the interdisciplinary team. Typically, surgical wound specialists include plastics, podiatry, orthopedics, or vascular/general surgery. Although many aspects of these surgical specialties overlap, well-established protocols should be recognized, defining when each specialty should be consulted. In general, plastic surgeons are experts in flaps, reconstruction, and restorative surgery. The podiatrist is well versed in surgical and medical management of the foot, ankle, and lower-extremity wounds and is often called upon to reduce risk factors associated with wounds and disease states that affect lower-limb mobility and ambulation. Normally, an orthopedic surgeon is required when extensive osseous involvement or contracture of joints is involved. When care of the wound requires assessing, monitoring, or reestablishing vascular status or if extensive abdominal surgical debridement is required, physicians should consider consulting the vascular/general surgeon. Any of these specialists would be diligent in their care and should be considered an excellent choice to have as a member of a team that is knowledgeable in each specific aspect of wound management.
       Repeatedly, sequelae are found in the wound patient, which trap him or her in a cycle of healing and nonhealing. There are several specialties that may need to be called upon for expertise in ancillary treatment and care. Many will be listed generally for completion; however, the full descriptions of each specialty are not within the scope of this article.
       Many diabetic patients will require care and monitoring from an endocrinologist/diabetologist to prevent and enhance healing of diabetic wounds. A pharmacist may be called upon to interpret certain antibiotic regiments via pharmacokinetics and/or discuss dosage regiments in complicated or high-risk patients. A gerontologist can be helpful in treating patients who have impaired cognitive issues, advanced age, or are required to use multiple prescription medications.
       Hyperbaric oxygen therapy has gained increased use and value in the management of hypoxic/avascular type wounds, and specialists in this area are gaining greater importance as research proves the potential benefits of this mode of treatment. Additionally, pain is the most common symptom/psychosocial factor adversely affecting the functional status and quality of life (well being) of the wound patient.⁶ If traditional methods of pain relief fail, consider utilizing an algologist or pain management specialist for more optimal outcomes. The infectious disease specialist is often called on to coordinate specific antibiotic/antifungal therapies and monitor the effect on the entire patient as well as the infected body part. Pathologists/dermopathologists are used to identify pathological tissues, which may be atypical, malignant, or rare in those patients with unusual nonhealing patterns. Radiologists are often needed to perform specific tests to rule out occult processes like osteomyelitis or situations that require advanced radiography or nuclear medicine (ie, magnetic resonance imaging, traditional or magnetic resonance arteriography, or bone scans). Finally, 2 important physical medicine specialties include the pedorthotist and orthotist, who are crucial for the construction of offloading orthoses, shoe gear modifications or designs, and prosthetics that will enhance mobility while allowing for healing to occur or be maintained. Also important is the manual lymphatic drainage (MLD) therapist, who is specifically trained to manage lymphedema of the extremities as well as recommend custom support garments and hosiery to avoid further risk of skin breakdown due to increased fluid retention pressures.

Advanced Wound Care Manufacturers and Distributors

       Advanced skin and wound care manufacturers, distributors, specialists, and industry members can offer clinical support, assistance, and backing with product choice. This group can also offer value-added services, such as education and training, inservices, continuing education units (CEU) and continuing medical education (CME) programs, and clinical support in the form of wound care specialists. A few industry businesses offer a “hot line” or answer line operated by clinicians who are available during office hours to assist with wound issues. ConvaTec^®, a Bristol-Myers Squibb Company (Princeton, NJ), has on-staff nurses and customer care professionals standing by to answer calls through ConvaTec’s Professional Services at 800-422-8811. The Advanced Wound and Skin Care Division of Medline Industries, Inc. (Mundelein, Ill) has a hotline supervised by ET/WOCN nurses at 888-701-SKIN. Many industry websites list tools and tips, offer continuing education, and are invaluable to the clinician. HEALTHPOINT^® (Fort Worth, Tex), for example, now has a CEU/CME service offered at http://www.thewoundinstitute.com.

The Sum of its Parts is Greater than the Whole

       The interdisciplinary approach to wound care allows the wound specialist to rapidly and accurately assess patients’ wounds. This permits optimal healing and the best outcomes for the least amount of financial burden on the patient and healthcare system. This method also allows for further prevention of wounds and complications like infection. The more efficient the management of patients is, from an interdisciplinary view, the quicker the patient will heal and return to ADLs. Since most patients with chronic wounds have multiple comorbidities, it is prudent to include the previously mentioned specialists in an interdisciplinary approach to wound management. It will foster improved consistency in the treatment and evaluation of the wound patient.

Figure 2

       The multidisciplinary approach to the care of the wound patient encompasses his or her entire well being and requires a client-focused care plan. The clinicians primarily involved in hands-on wound care and decision making, as well as common referral groups important in the holistic approach to wound management, are reviewed in Figure 2.
       The importance of an interdisciplinary approach to wound care can best be summarized in the following quote from John MacDonald, MD, FACS, President-Elect of the Association for the Advancement of Wound Care (AAWC): “Due to the complexity of most chronic wounds, it is imperative that a comprehensive, multidisciplinary approach to care be taken in order to adequately address each contributing factor, to optimize care, and to improve outcomes.”⁷ In the AAWC’s Statement on Comprehensive Multidisciplinary Wound Care, the organization states, “Synergy develops from cross disciplinary care resulting in improved outcomes.”⁸

Case Study

       Ms. LD is an 80-year-old home health patient with diabetes and chronic foot ulcers. She has been hospitalized frequently in the last 3 years due to wound infection and labile blood sugars. She spent the last month and a half in long-term care for rehabilitation and gait training after a pathological fracture of the hip. The multidisciplinary wound care team consisted of a CWS for conservative debridement, dressing and adjunctive treatment selection, and patient/family education; an internist or diabetologist for treatment of her diabetes and glycemic control; a physical therapist for gait training and home modification; a registered dietitian to evaluate and monitor her diet, offer diet therapy for wound management, and educate on the importance of diet adherence; a podiatrist or general plastic surgeon for surgical intervention; an infectious disease specialist to address potential future infection and evaluate for osteomyelitis; a wound care nurse (WOCN and/or CWS) to assess healing, coordinate services, and provide local wound care; an orthotist to evaluate and provide corrective offloading footwear; and a case manager to provide clinical expertise in obtaining supplies and devices and coordinating the team’s efforts.
       The multidisciplinary approach paid off. Ms. LD’s wounds granulated and closed and have not recurred in several months. She has lost 22 lb, and her blood sugars were below 150 consistently. She always wears her pressure relief footwear, “even to go out and get the evening paper,” she reports. Without the attention to her overall health and diabetes, offloading, mobility, wound bed preparation, nutrition, viable blood flow, and pain management, her chronic wound may never have healed. The interdisciplinary team provided the right combination to close her wound and get her back on track.