Employing interdisciplinary team working to improve patient ... - EWMA

Presented at
EWMA 2011
Brussels · Belgium
Developing evidence-based ways of working:
Science, Practice and Education
Employing interdisciplinary team
working to improve patient outcomes in
diabetic foot ulceration – our experience
1. HISTORY AND INTRODUCTION
The treatment of wounds is an ancient area of
“specialization in medical practice”. Its origins
trace to ancient Egypt and Greece. The most profound
advances in the field came with the development
of microbiology and cellular pathology
in the 19 th century. In the 1870s, R.W Johnson,
the cofounder of Johnson & Johnson, began the
production of gauze and wound dressings with
Iodine. In the late 19 th century P.L. Friedrich
introduced the importance of wound excision, a
procedure that reduced the risk of infection and
thus surgery was on board….
The diabetic clinic at the Deaconess Hospital in
Boston can be considered as one of the first to
instigate a multidisciplinary approach in diabetic
wound care, bear in mind that the discovery of
insulin was still a few years ahead! The teaching
of diabetic foot care was considered so important
that by 1928 they had assigned one graduate nurse
and two pupil nurses to that duty. 1
From the moment we use the term “specialization
in different fields of wound care” we are
already speaking about multidisciplinarity.
2. DEFINITION OF A
MULTIDISCIPLINARY TEAM
We have found some different explanations/definitions
of a multidisciplinary team:
“…A group of people with different kinds of
training and experience working together, usually
on an ongoing basis. Professionals often use the
word “discipline” to mean a field of study such
as medicine, social work, or education…” (www.
dwp.gov.uk department for work and pensions).
“A group composed of members with varied
but complementary experience, qualifications,
and skills that contribute to the achievement of
the organization’s specific objectives” (Oxford
Dictionary).
“A multidisciplinary team is composed of
members from different healthcare professions
with specialized skills and expertise. The members
coordinate and communicate with each other to
provide quality patient care. Coordination and
teamwork among clinicians results in greater efficiency
and improved clinical outcomes” (Journal
of Healthcare Quality, March/April 2004). 2
In our further work we try to clarify why the use
of some words will play a major role and why
perhaps the terminology of multidisciplinarity is
not our favourite in our context of teams concerning
wound care.
3. WHY WE SHOULD USE
INTERDISCIPLINARY IN THE CONTEXT
OF WOUND CARE?
A two-step approach
a. Difference between professionals and
disciplines.
We are privileged that an expert as respected as
Paul Gorman wrote several articles and books
about multidisciplinary teams. He helped us to
understand the differences and nuances between
professionals and disciplines. 3
It’s fascinating to question why we have developed
different disciplines in medicine. As human
beings we have learnt that specialization enables
us to know more about things. Receiving greater
depth of knowledge will give us greater control
over that part of our world and our environment.
At the same time, other people have specialist
knowledge about other things. Coming together
we will have an even greater area of knowledge.
Knowledge, but also status, reward and power, are
divided by the boundaries of professions and disciplines.
To demonstrate this Paul Gorman gave
us the following examples: doctors get paid better
than nurses and in some environments, have more
status and power. Gender too plays a crucial role
Kristien Van Acker
Diabetologist, Md, PhD
Chimay, Rumst,
Vice Chair DFP, IDF,
Consultant Trop Inst
Antwerp, Belgium
Correspondence:
stiebertje.viroin@
gmail.com
Conflict of interest: none
EWMA JOURNAL 2012 VOL 12 NO 2 31

in the way professions operate internally and the way they
interact with each other. This lead to defining the mission
statements of the professional bodies (e.g. podiatry,
chiropody and nursing); in history we see the development
of professional bodies, acting as gatekeepers to the professions.
Those bodies control the right to practice and will
protect the public from charlatans, and this can only be
seen as an advantage. However an individual, namely a patient,
is not approached on a daily basis by the professional
bodies but by medical teams. For this reason, it’s preferable
to speak in terms of multidisciplinary teams (MTs) instead
of multi-professional teams. In MTs members of staff, like
auxiliaries, receptionists, and all the others also have a
central role. Another important point is that the patients
and their relatives have also a central place, which is not
in the case in a multi- professional team.
b. Difference between multidisciplinary (MTs) and
interdisciplinary teams (ITs)
In 2007 Rebecca L Jessup from Australia was one of the
first to adopt the concept of interdisciplinary teams and
their skills and behavior 4 .
According to Paul Gorman, MTs utilize the skills
and experience of individuals from different disciplines,
with each discipline approaching the patient from its own
perspective. More often than not, this approach involves
separate individual consultations. These may occur in a
“one-stop-shop” fashion with all consultations occurring
as part of a single appointment on a single day. It is common
for this team to meet regularly, in the absence of the
patient, to “case conference” findings and discuss future
directions for the patient’s care. MTs provide more knowledge
and experience than disciplines operating in isolation.
ITs, however, integrate separate discipline approaches
into a single consultation, i.e. the patient-history taking.
The team, together with the patient, conducts assessment,
diagnosis, intervention and short- and long-term management
goals at the one time. The patient is intimately
involved in any discussions regarding their condition or
prognosis and the plans about their care. Individuals from
different disciplines, as well as the patient themselves, are
encouraged to question each other and explore alternate
avenues, stepping out of discipline silos to work toward
the best outcome for the patient. In these processes, family
members and partners will also be involved in the plans
about the care of their family member. Those who have
experience in this approach will immediately recognize a
personal expression: “working in the order of chaos!” The
energy and general demands are huge but the rewards are
great, and perhaps the most important benefit is the richness
of the contacts of team members with the patients
and their family with, in return, the confidence the patient
gives back even when prognosis is poor.
32
4. WHAT CAN BE CONSIDERED AS
“PRACTICAL” GOLDEN RULES
For teambuilding and working in an interdisciplinary
team? 5-9
No-one anywhere can start such an Interdisciplinary Team
Project without a respectable time of preparation and a
clear concept of the project management in which he/she
has to take at least four characteristics into account: definite
duration, examine the logic relationship with other
activities in the project, study the resource consumption
of this team (information, energy, know how, time and
financial resources) together with the associated costs. This
means that at the very least, for long-term success, a person
must develop a business plan and management skills.
The initiative taker will define roles and boundaries.
Everyone needs clarity on his/her own role and it has to
be clear to each member what other team members do.
The team coordinator has to be aware of power dynamics
within the group, i.e. are certain members competing
for control? Or do some have more status than others?
The process of “taking decisions” must be analyzed on
a constant basis in the team; how, who and when is important.
Team members must learn to value each other’s
contributions and look at how the group communicates.
In addition, they have to be aware that “different professionals
have different views” and that this is the added
value of the concept.
Implementation of feed-back loops for self-evaluation
is helpful in detecting some barriers and is of utmost importance
to the success of ensuring members do not underestimate
the value of listening to service users (patients).
Often small details are huge barriers to team success. Some
of the biggest barriers include unclear goals, unhealthy
communication, playing it ‘safe’, individual goals and poor
leadership.
5. INTERDISCIPLINARY TEAMS IN DIABETIC
FOOT WOUND CARE
a. Rationale and evidenced based data
One example of where building an interdisciplinary team
is useful and effective is the diabetic foot team. We refer to
the International Consensus of the Diabetic Foot, audited
by Karel Bakker and first launched in 1996 and the fourth
edition recently launched at the International Diabetic
Foot Meeting in May 2011 in Noordwijkerhout 10 .
In this consensus the following statements can be
found: “If you have a foot problem, you should obtain
foot care from a multidisciplinary foot team. A multidisciplinary
approach has been shown to bring about a 45-85%
decrease in amputations”. This sounds impressive, so what
are the references and the associated evidence?
The first publication on multidisciplinary diabetic foot
clinics was published in 1986 by Mike Edmonds in which
EWMA JOURNAL 2012 VOL 12 NO 2

he illustrated the improved survival of the diabetic foot
and the role of a specialized foot clinic. 11 In 2005 Lavery
LA published the outcome of a study of 2738 persons
with diabetes carried out over 28 months. Stratification
into low and high-risk groups was performed with the
implementation of preventive or acute care protocols.
The outcome was impressive: a 47% decrease of the incidence
of amputations; 38% reduction in foot-related
hospital admissions; 22% reduction of average hospital
days and 70% reduction in SNF (skilled nursing facilities)
admissions. 12 This model has been widely replicated; the
group of Gerry Ryman 13 illustrated a significant reduction
in total and major amputation rates in a defined U.K.
population measured over an 11-year period (1995-2005)
following improvements in foot care services including
multidisciplinary teamwork. Expressed as incidence per
10,000 people with diabetes, total amputations fell 70%,
from 53.2 to 16.0, and major amputations fell 82%, from
36.4 to 6.7. This was also the result of a continuous prospective
audit.
b. How to establish a diabetic foot clinic
Some years ago, the IWGDF convened a roundtable meeting
to discuss the principles of organizing a diabetic foot
clinic. We published these data in the Time to Act in the
year of the “Diabetic Foot”, 2005 14 . The idea of the working
group was to make a distinction between three models:
The minimal model or basic model, the intermediate
model, and the centres of excellence also called tertiary
referral centres model. In practice, the gradual process
towards excellence is initiated by a dedicated individual,
a “local champion”, working in a very small team. More
often than not, this person drives the project for many
years and he or she assumes much of the responsibility
from the start.
Please visit the IWGDF website for more information: www.iwgdf.org
Table 1: The Different Models of Diabetic Foot Care according to the IWGDF.
Science, Practice and Education
In Table 1 we present the three models and refer to
the publication of Time to Act for more details. By accepting
the concept of this “Three Level Model”, we are
aware that referral patterns between these levels of care in
this global organization must be clearly defined. This will
only be possible if the organization in the country has a
well-established centre of excellence. Good structures will
have a positive influence on reducing delays in referrals!
c. The importance of feedback loops and benchmarking:
Quality control
Delivery of good diabetic foot care is also dependent on
the need for feedback and self reflection if we are to witness
improvements in the performance of the teams which in
turn lead to improvements in the delivery and outcome
of the medical care 15 . To evaluate the input, or the intervention
(e.g. “multidisciplinary diabetic foot clinic”)
and the process itself we have to register the outcome
parameters for our evaluation. There are many examples
of such processes. One of the modern techniques used is
benchmarking.
One of the first important studies to compare differences
by centre is the EURODIALE 16-18 . In this study (a
prospective cohort study of 1232 consecutive individuals)
we learned that treatment of many patients is not in line
with current guidelines and there are large differences between
countries and centres. At study entry, 77% of the
patients had inadequate or no offloading. During followup,
casting was used in 35% (0-68% variation between
countries!) of the plantar fore- or midfoot ulcers. Vascular
imaging was performed in 56% (14-86%) of patients with
severe limb ischemia; while revascularization was (only)
performed in 43%.
At the current moment only two countries, namely
Germany and Belgium, are known to have this quality
control system. In the disease-management programme
in Germany, providers are obliged to refer high-risk feet,
ulceration and suspicion of diabetic osteoarthropathy to
specialized diabetic foot clinics at predefined interfaces.
Minimal Model Intermediate Model Maximal Model
Staff Doctor/nurse or
podiatrist
Aim Prevention and basic
curative care
Doctor or General Physician
Surgeon
Podiatrist and/Nurse
Orthotist
Prevention and basic curative care for
all types of patients and advanced assessment
and diagnosis
Patients Own patients From the regional catchment area of
the hospital with possibly some referrals
from outside the region
Setting Small regional hospital,
health centres
Diabetologist/surgeon/rehabilitation
specialist/microbiologist/dermatologist/
Psychiatrist/nurse/educator/podiatrist/
casting technician/secretarial staff...
Prevention and specialized curative care
provide training for other centres
National, regional or even international
reference centre
Hospital Reference centre (Third line centre)
EWMA JOURNAL 2012 VOL 12 NO 2 33

Science, Practice and Education
An interdisciplinary Diabetic Foot Team in action: Order in the Chaos. Diabetic Foot Clinic – Kristien Van Acker
Standards of Quality for Specialized Diabetic Foot Clinics
according to the Criteria of the Diabetic Foot Working
Group of the German Diabetes Association (DDG) are
based on Structural quality (equipment, documentation,
and staff); Structural- and Process quality (interdisciplinary
cooperation by contract); Process quality (clinical
pathways/standard operation procedures (SOP); Hygiene
plans, (MRSA management plan); Audit (active and passive);
and Quality of performance (treatment results of 30
consecutive patients).
In Belgium, some opinion leaders together with Scientific
Institute of Public Health, Epidemiology in Brussels
developed an “Initiative for Quality of Care Promotion
and Epidemiology in Belgian Diabetic foot clinics”, the socalled
IQED centres. This prospective study is designed to
describe, evaluate and improve the Quality of Care in the
Belgian diabetic foot clinics (DFC) by collecting data and
providing benchmarking. In this study Off-loading was
used in 75% (variation from 42% to 100%) of the ulcer
patients, but a total contact cast was only used in 2.4%.
Of the patients with peripheral arterial disease, 42.8% underwent
revascularization and 59.4% were hospitalized 19 .
34
6. GENERAL CONCLUSIONS AND THE
CONCEPT OF INTERDISCIPLINARY TEAMS
FOR INTEGRATED WOUND CARE
In many countries and societies care facilities have come
a long way in developing their wound care programs,
especially where there is more effort towards an interdisciplinary
approach. They have moved away from the
approach of just having a single wound treatment nurse
and established a more integrated care approach. The most
successful teams are those that have a wound care team
involving all key departments within the facility. In hospitals
it starts with the medical director who facilitates
the necessary patient medical work-ups as, for example, a
therapy to apply specific services such as modalities and
wound debridement, and dietary services to ensure that
those with wounds have adequate nutritional intake. On
the other hand, well skilled home nurses who provide
primary patient care including wound dressings are also
important key players. But in this advanced situation the
key pitfall will be a good referral system and communication
between the first, second and tertiary line teams.
Ultimately, highly coordinated treatment plans are effective
in reducing average wound healing times, thereby
lessening patient suffering and costs of care.
EWMA JOURNAL 2012 VOL 12 NO 2

In this philosophy we must consider today integrating
all the different “thematic” teams. Personally, I believe in
an integration of teams specialized in wound care of diabetic
foot ulcers, pressure ulcers, venous ulcers and others.
This is already the case in some countries, such as the U.S.
Finally, I would like to conclude that all worldwideknown
diabetic foot clinics, the so called ‘Centres of
Excellence’, were created one step at a time, beginning
with the basic model. This paper has reported the experience
of building one. This may be of use to those clinical
personnel who are considering the effectiveness of their
ways of working and the associated patient outcomes. We
have reported improved patient outcomes following the
implementation of this evidence-based model and would
encourage others to consider employing this approach.
‘A journey of a thousand miles begins with one step…’
Lao Tzu, China, 6 th century
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