Abstract
Multidisciplinary care of pressure sores is organized in the department of physical medicine and rehabilitation of R.-Poincare hospital since 2010. The patients’ selection is performed after a telephone conversation (214 patients in 2011). Patients from Ile de France area with neurological pathologies are selected for the follow-up (spinal cord injury, multiple sclerosis, spina bifida). A physician and a nurse see together the patients the first time. The follow-up is secondary performed essentially by a nurse. Two times per month, patients with a surgical indication are showed to a plastic surgeon. Two thirds of the patients need a medical healing, one third need a surgical procedure. One important part of the follow-up is dedicated to prevention and information of patients. A physiotherapy or occupational therapy evaluation is proposed to patients according to their needs (transfers, wheelchair choice, cushion, home and car layouts. . ..). A social, psychological and dietetic follow-up is proposed to the patients. A program of therapeutic education is organized since 2011, validated by the regional health agency. Among 110 patients followed-up during 2011, 84 benefit from a therapeutic education program. One multidisciplinary consultation is organised each month including PMR physicians, plastic surgeon, nurses, physiotherapist, occupational therapist, dietician, social worker. Five to six patients with complex medical history are seen each month to discuss the therapeutic strategy. Collaboration is also necessary with internal medicine department (infectious and nutritional disorders) and orthopedic surgery department (bone infection). If urological or bowel-stomy are necessary, specialized surgeons are requested. Pressure sores care need a multidisciplinary team involving numerous stakeholders. Prevention, therapeutic education, medical and surgical care are the different elements to organize in order to ensure an optimal care of patients.
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