Team Management of Acute Hip Fracture Patients

Dear Readers:   Multidisciplinary teams wielding evidence-based protocols report improved acute¹ and chronic^2,3 wound outcomes; however, few have tested this hypothesis in a randomized controlled trial (RCT) comparing team care to a non-team standard of care (SOC). This edition of Evidence Corner explores RCTs testing whether teams really do work. One study in Taiwan investigated long-term interdisciplinary postoperative care in elderly subjects with hip fractures. The second, in Australian skilled nursing facilities, explored healing and costs for SOC compared to those resulting from team care to manage skin tears, leg ulcers, and pressure ulcers. Both studies conclude that team care works. Read on to discover why it is so difficult to answer this question. Laura Bolton, PhD, FAPWCA Adjunct Associate Professor Department of Surgery, UMDNJ WOUNDS Editorial Advisory Board Member and Department Editor

Team Management of Acute Hip Fracture Patients

  Reference: Shyu YI, Liang J, Wu CC, et al. Two-year effects of interdisciplinary intervention for hip fracture in older Taiwanese. J Am Geriatr Soc. 2010;58(6):1081–1089.   Rationale: Early multidisciplinary postoperative rehabilitation, discharge planning and transitional care improve initial outcomes of elderly patients with hip fracture and reduce in-hospital mortality and medical complications, but effects on 2-year outcomes remain to be explored in RCTs.   Objective: Conduct a RCT comparing effects of interdisciplinary team care (TC) or SOC of elderly hip fracture patients on clinical outcomes, self-care ability, health-related quality of life (HRQoL), service utilization, and depressive symptoms for up to 2 years after discharge.   Methods: A prospective, single blind RCT conducted at a 3000-bed medical center in northern Taiwan randomly assigned 82 geriatric inpatients to TC or SOC. TC included geriatric consultations, patient education, a continuous exercise and rehabilitation program, and discharge-planning service. In the hospital, TC patients received 1 geriatrician visit, and means of 5.4 geriatric nurse visits, 3.1 physical therapist visits, and 1 rehabilitation physician visit. After discharge TC patients received means of 9.9 geriatric nurse visits and 3.0 physical therapy visits at home. SOC patients were admitted to the care of an orthopedist with internist and anesthetist consultations as needed. All subjects had appropriate auxiliary care including appropriate pain relief, antibiotics, x-rays, electrocardiogram, blood chemistry and cell counts. Patients were usually discharged 5–7 days after surgery with no provision made for at-home rehabilitation, physical therapy or nursing care for SOC patients. Main outcomes reported were mortality, service utilization including hospital readmissions, emergency room visits, institutionalization, hip flexion ratio (HFR), peak force of the fractured limb’s quadriceps, 50-yard walking test, self-care abilities, fall occurrence, HRQoL, and depressive symptoms. Statistical likelihood of effects was calculated using a generalized estimating equation to compensate for bias due to dropouts during follow up at 1, 3, 6, 12, 18, and 24 months after surgery.   Results: TC and SOC groups were similar on gender, age, marital status, education, type of surgery, pre-fracture self-care ability, walking ability, length of hospital stay, number of comorbid diseases, fracture type, American Society of Anesthesiologists rating, time from admission to surgery, and drop-out rates and mortality after discharge. TC patients improved more than SOC patients (P Authors’ Conclusions: This interdisciplinary intervention focused on elderly hip-fracture patients provided significant benefits for geriatric patients with a hip fracture in Taiwan.

Skilled Nursing Facility Teams Improve Wound Outcomes for Less Money

  Reference: Vu T, Harris A, Duncan G, Sussman G. Cost-effectiveness of multidisciplinary wound care in nursing homes: a pseudo-randomized pragmatic cluster trial. Fam Pract. 2007;24(4):372–379.   Rationale: Nurses and hospital pharmacists play important roles on hospital wound care teams. Community pharmacists provide a variety of public services, including supplying nursing homes with prescribed products and medication reviews. This role may easily extend to wound care, but there is no research exploring pharmacists’ contributions to wound care outcomes in nursing homes.   Objective: Test the hypothesis that a team intervention by trained pharmacists and nurses using a standardized wound treatment protocol (TCP) would improve skilled nursing home wound outcomes and reduce costs of care for acute skin tears and chronic leg and pressure ulcers compared to those associated with SOC in which only nurses are involved in wound care.   Methods: A pseudo-randomized pragmatic cluster trial was conducted from 1999–2000 in 44 high-care nursing homes in metropolitan Melbourne, Australia. Each TCP nursing home was matched to a similar one practicing SOC in the same region. Residents with skin tears, pressure or leg ulcers were included. Those with infected wounds, diabetes, or receiving steroid, anti-inflammatory or immunosuppressive treatment or chemotherapy were excluded. Outcomes measured included wound size, a short-form, 36-item general health questionnaire and Assessment of Quality of Life Index on study enrollment and exit. The primary outcome was percent of wounds healed in each arm of the study, estimated using a Cox regression model to adjust for confounding variables. Total pain relief was recorded if a patient achieved a pain score of zero during the 20-week trial period. Costs estimates included wound-care related staff time, training, products, and waste disposal. Chi square tests compared the groups on categorical outcomes. Group outcomes measured as continuous variables were compared using t tests or Mann-Whitney tests.   Results: The 21 TCP nursing homes serviced by 10 pharmacies enrolled 94 residents with 180 wounds. The 23 SOC nursing homes enrolled 82 residents with162 similar wounds. Groups were comparable on age, length of stay in nursing homes, wound risk due to incontinence and ability to describe pain and discomfort. TCP patients were more likely to have extremes of weight and less likely to have a history of leg or pressure ulcers compared to SOC residents (P P P P > 0.10). Results were similar if pressure and leg ulcers were analyzed together or separately. Confounding variables increased variability so that only multivariate outcome analyses were statistically significant. Covariates significantly predicting healing included wound width, wound depth, and patient frailty (P Author’s Conclusions: Adding Australian pharmacists to the nursing home wound care team significantly benefitted patients and reduced costs of care when the team implemented a standardized protocol supporting wound management decisions and services.   Clinical Perspective   Together, these two RCT provide strong support for team wound care confirming non-RCT conclusions of improved outcomes and lower costs of managing such diverse wound challenges as chronic wounds in skilled nursing facilities,⁴ or a university-based wound clinic⁵ or postsurgical infections in the surgical intensive care unit.⁶   This research reminds us that team care is practiced using standardized protocols of care. It is difficult to separate the effects of the protocol from those of the team. Both work in synergy. If teams win better wound outcomes than SOC protocols power this victory by clearly spelling out who does what to whom and by when. Without the protocol, contributions by each team member may be ignored or misused. Imagine the results of ignoring microbiology or orthotic lab reports or pharmacist medication reviews. The results of superb surgery may be undone by slipshod wound care or lack of physical therapy. Conversely, without team implementation, the protocol would accomplish little. All team members depend on each other “doing the right thing to the right patient at the right time” to achieve sterling outcomes.⁷   Research also reinforces the value of including the patient on the team. Consistent patient-oriented exercise and rehabilitation programs help restore an individual’s capacity to do activities of daily living following acute hip fracture.⁸ Involving patients is recommended for chronic wound management too.⁹ The advantages of team care remind us that every wound is connected to a person whose condition and actions contribute to wound progress. Teams help us recognize and address what is needed to heal a wound and engage all possible forces in achieving a person’s wound care goals.   References 1. Gottrup F. Optimizing wound treatment through health care structuring and professional education. Wound Repair Regen. 2004;12(2):129–133. 2. McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care. 2008;21:75–78. 3. Lyder CH, Shannon R, Empleo-Frazier O, McGeHee D, White C. A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes. Ostomy Wound Manage. 2002;48(4):52–62. 4. DaVanzo JE, El-Gamil AM, Dobson A, Sen N. A retrospective comparison of clinical outcomes and Medicare expenditures in skilled nursing facility residents with chronic wounds. Ostomy Wound Manage. 2010;56(9):44–54. 5. Steed DL, Edington H, Moosa HH, Webster MW. Organization and development of a university multidisciplinary wound care clinic. Surgery. 1993;114(4):775–778. 6. Price J, Ekleberry A, Grover A, et al. Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit. Crit Care Med. 1999;27(10):2118–2124. 7. King TA. Deputy Director, Office of Clinical Standards and Quality Centers for Medicare and Medicaid Services. Defining Quality Health Care According to the Agency for Healthcare Research and Quality. Presented at CMS, July 15, 2005. Accessed: August 18, 2011. Available at: https://www.allhealth.org/briefingmaterials/King-199.pdf. 8. Adunsky A, Lusky A, Arad M, Heruti RJ. A comparative study of rehabilitation outcomes of elderly hip fracture patients: The advantage of a comprehensive orthogeriatric approach. J Gerontol Biol Sci Med Sci. 2003;58A:M542–M547. 9. Van Hecke A, Grypdonck M, Defloor T. Guidelines for the management of venous leg ulcers: a gap analysis. Eval Clin Pract. 2008;14(5):812–822.