Open Access Highly Accessed Research article

Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic cluster randomized stepped wedge trial in long term care

Anita Stern1*, Nicholas Mitsakakis2, Mike Paulden3, Shabbir Alibhai4, Josephine Wong2, George Tomlinson5, Ann-Sylvia Brooker2, Murray Krahn2 and Merrick Zwarenstein6

Author Affiliations

1 ELLICSR, University Health Network, 200 Elizabeth Street, Munk Building, BCS021, Toronto, Ontario M5G 2C4, Canada

2 THETA, Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College StreetToronto, Ontario M5S 3 M2, Canada

3 Faculty of Medicine & Dentistry, University of Alberta, 736 University Terrace, 8303 112 St, Edmonton, AB T6G 2 T4, Canada

4 Toronto General Hospital, Eaton 14th Floor Rm 14EN214, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada

5 Toronto General Hospital, Eaton North Wing, 13th Floor Rm 13EN238, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada

6 Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, 245-100 Collip Circle, Research Park, London, Ontario N6G 4X8, Canada

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BMC Health Services Research 2014, 14:83  doi:10.1186/1472-6963-14-83

Published: 24 February 2014



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


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.


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.


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.

Trial registration identifier NCT01232764

Pressure ulcer; Long term care; Nursing home; Multi-disciplinary team; Chronic wound; Treatment