Working with pressure and/or wounds is a lot like working on a jigsaw puzzle. Having all the pieces is one thing; having them interconnect provides the solution for the full picture.

For many years the staff at Parkwood Hospital have created numerous health care pieces. In 1998, one of those pieces, the recently formed Wound Management Clinic Team sat down to create their mission and vision. During this process, one of the steps was to look at our stakeholders, key relationships and the areas where there may be overlap. A list was developed of services/professionals on site that already provides a "piece" of the care related to skin health. This list included: Inpatient Skin Teams; an Inpatient Skin Clinic; Chiropody; Seating Program; practitioners of therapeutic positioning; Continence Specialist and Clinic; nutritionists; epidemiologists; Wound Research Group; a Research Department and an affiliated university.

From this list, the need for a more cohesive and interdisciplinary approach to skin care was identified and thus was born the Chronic Wound Care and Skin Health Team. Through this group, members have learned much about wounds and skin health and the services and skills each service/profession is able to provide. Members have supported one another, and their peers within the facility, in the areas of education, research and clinical practice. This shared learning has broadened the therapeutic benefits by each clinician.

Management of chronic wounds including pressure ulcers requires a global interdisciplinary approach to the patient. Recently the Canadian Association of Wound Care has published recommendations for best practice in preparing the wound bed and the prevention and management of pressure ulcers.

In this approach, the clinician is directed to find and alleviate the underlying cause as well as treat the wound and address patient centered concerns. In the treatment of pressure ulcers a coordinated interdisciplinary approach involving nurses, physicians, dieticians, occupational therapists and physiotherapists is required for optimal management. While physicians and nurses may provide good local wound care, good pressure downloading and proper nutrition are essential components of skin care that address the underlying causes. The best wound care, if provided in isolation, will not ensure wound healing. Contributing factors need to be analyzed to determine potential causes and the appropriate services/professionals that need to be involved to maximize wound healing and improve the patient’s quality of life.

- left heel: 12 cm x 10 cm Stage IV ulcer with a calcaneus palpable at the bottom of the ulcer and 95% covered with necrotic tissue.

• Poor nutrition: She was anaemic and malnourished. Serum albumin was low at 25.
• Incontinent of bowel and bladder.
• Decreased mobility: Ms. C. was dependent for all her gross motor function, bed mobility and ADL’s. She was being transferred by a mechanical lift but did not have an appropriate seating system to allow her to get out of bed. Ms. C. also had hip and knee flexion contractures.

Ms. C. was assessed by Occupational Therapy and Physiotherapy for the development of a therapeutic positioning program. Custom foam wedges were fabricated to achieve pressure relief over her heels and to prevent further skin breakdown due to her legs from crossing over. Nursing staff were repositioning Ms. C. every two hours.

A wheelchair and seating assessment was also completed by the seating team. On admission, Ms. C. did not have an appropriate seating system and could not get out of bed. A wheelchair trial consisting of a Concept 45 manual dynamic tilt wheelchair with a standard personal back, Ottobock headrest, low profile Roho cushion, seatbelt, lap tray and custom legrest panel was started. Initially, her sitting tolerance was limited to one hour a day but by the time of discharge, it had increased to three hours. Pressure mapping readings indicated that the low profile Roho cushion used in combination with the dynamic tilt feature of the chair was providing good pressure reduction. A behavioural change was noted when she was sitting up in the chair. Ms. C. was not crying out as much and enjoyed the interaction with her surroundings. As a result of the improved positioning with this seating system, she was attempting to propel herself and was able to self-feed with setup and cueing.

- coccyx: 2 cm x 3 cm, 1 cm deep

- upper right greater trochanter: 4 cm x 1.4 cm, 1 cm deep, sinus at 6 o’clock, 3.8cm deep

- right greater trochanter: 5 cm x 1 cm

Consultation was provided to the nursing home and community service providers to facilitate continuity of care.

An interdisciplinary patient centered approach was used to develop a management program to promote healing of Ms. C.’s multiple decubiti and also to prevent the development of further breakdown. The provision of an appropriate seating system for Ms. C. promoted the opportunity for mobility, physical skin functioning, social interaction and increased quality of life without compromising skin care management.