Abstract
BackgroundThe study was conducted to determine the clinical and cost effectiveness of enhanced multi-disciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, CanadaMethodsWe conducted a multi-method study: a pragmatic cluster randomized stepped-wedge trial, ethnographic observation and in-depth interviews, and an economic evaluation. Long term care facilities (clusters) were randomly allocated to start dates of the intervention. An advance practice nurse (APN) with expertise in skin and wound care visited intervention facilities to educate staff on pressure ulcer prevention and treatment, supported by an off-site hospital based expert multi-disciplinary wound care team via email, telephone, or video link as needed. The primary outcome was rate of reduction in pressure ulcer surface area (cm2/day) measured on before and after standard photographs by an assessor blinded to facility allocation. Secondary outcomes were time to healing, probability of healing, pressure ulcer incidence, pressure ulcer prevalence, wound pain, hospitalization, emergency department visits, utility, and cost.Results12 of 15 eligible LTC facilities were randomly selected to participate and randomized to start date of the intervention following the stepped wedge design. 137 residents with a total of 259 pressure ulcers (stage 2 or greater) were recruited over the 17 month study period. No statistically significant differences were found between control and intervention periods on any of the primary or secondary outcomes. The economic evaluation demonstrated a mean reduction in direct care costs of $650 per resident compared to ‘usual care’. The qualitative study suggested that onsite support by APN wound specialists was welcomed, and is responsible for reduced costs through discontinuation of expensive non evidence based treatments. Insufficient allocation of nursing home staff time to wound care may explain the lack of impact on healing.ConclusionEnhanced multi-disciplinary wound care teams were cost effective, with most benefit through cost reduction initiated by APNs, but did not improve the treatment of pressure ulcers in nursing homes. Policy makers should consider the potential yield of strengthening evidence based primary care within LTC facilities, through outreach by APNs.Trial registrationClinicalTrials.gov identifier NCT01232764
Highlights
The study was conducted to determine the clinical and cost effectiveness of enhanced multidisciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, Canada
The high levels of satisfaction and engagement by LTC staff with the outreach advance practice nurse (APN) when present in the LTC facility, we suggest that the intervention be more likely to succeed given a longer period of implementation, and that the whole of this be conducted using face to face APN support, rather than remote, approaches
pressure ulcer (PU) tend to be largely overlooked as LTC facility staff are busy reacting to more pressing issues, and due to incentives in the reimbursement policies in place at the time this study was conducted, facilities could get extra costs related to wound care covered by the Ministry of Health and Long-Term Care (MOHLTC) once residents had advanced PU’s, reducing the incentive to address wounds proactively
Summary
The study was conducted to determine the clinical and cost effectiveness of enhanced multidisciplinary teams (EMDTs) vs. ‘usual care’ for the treatment of pressure ulcers in long term care (LTC) facilities in Ontario, Canada. A pressure ulcer (PU), known as a pressure sore, decubitus ulcer, or bedsore, is a localized injury to the skin and/or underlying tissue caused by pressure and/or shear [1]. Those at greatest risk for developing PUs are the elderly, the critically ill, the neurologically impaired, and those who suffer from conditions associated with immobility [2]. In 2007 the National Pressure Ulcer Advisory Panel added 2 categories of PUs: Deep Tissue Injury (DTI) (intact discolored skin due to damage to underlying soft tissue), and Unstageable (full-thickness tissue loss, depth unknown due to slough or eschar on the wound’s surface) [1]. Pain [7], depression [8], altered self-image [8], and increased morbidity and disability [9] are consequences of this largely preventable condition
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