title: Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care.
abstract: BACKGROUND
  The 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, Canada
  
  
  METHODS
  We 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.
  
  
  RESULTS
  12 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.
  
  
  CONCLUSIONS
  Enhanced 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.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier NCT01232764.
authors.affiliation: ELLICSR, University Health Network, 200 Elizabeth Street, Munk Building, BCS021, Toronto, Ontario M5G 2C4, Canada. anita.stern@rmp.uhn.ca.
authors.forename: Anita
authors.initials: A
authors.lastname: Stern
authors.forename: Nicholas
authors.initials: N
authors.lastname: Mitsakakis
authors.forename: Mike
authors.initials: M
authors.lastname: Paulden
authors.forename: Shabbir
authors.initials: S
authors.lastname: Alibhai
authors.forename: Josephine
authors.initials: J
authors.lastname: Wong
authors.forename: George
authors.initials: G
authors.lastname: Tomlinson
authors.forename: Ann-Sylvia
authors.initials: AS
authors.lastname: Brooker
authors.forename: Murray
authors.initials: M
authors.lastname: Krahn
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
mesh_terms: D000328:Adult; D000368:Aged; D016000:Cluster Analysis; D003362:Cost-Benefit Analysis; D005260:Female; D006302:Health Services Research; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D010348:Patient Care Team / Q000191:economics*; D003668:Pressure Ulcer / Q000453:epidemiology / Q000628:therapy*; D015995:Prevalence; D017216:Telemedicine / Q000191:economics*; D016896:Treatment Outcome; D014945:Wound Healing