CAWC CAWC
CAWC Home    
         

Clinical Practice

The Interdisciplinary Urgency Tool – A Comprehensive Wound-Care Referral Form

by Richelle Gorst, BSc, PT; Gillian Bagg, BSc, OT; Martine Albert, BScN; and Nancy Couture, RN

Abstract

Successful and comprehensive wound-care management requires referrals to be appropriate and timely. The Skin and Wound Assessment and Treatment (SWAT) Team of Calgary Health Region’s Care in the Community Program identified gaps within the referral process among home-care staff. The current process was inconsistent throughout the program, pertinent information was frequently not available at the time of referral, and there was often a delay in recognizing the need to refer to the SWAT Team. Consequently, a preventative approach to providing wound care to the clients was hindered, and as a result, the Urgency Tool was devised. This Tool acts as a referral form, which is composed of a checklist of key risk factors that utilizes the modified VIP (vascular, infection, pressure) paradigm as a trigger for the wound-care clinician. The paradigm has been adapted to guide the practitioner in considering all interdisciplinary aspects of wound care prior to initiating the referral and to promote consistency when making a referral to the SWAT Team. Benefits of implementing the Urgency Tool are that the practitioner will recognize that a higher number of risk factors equals a more urgent referral.

About the Authors
The authors are members of the Skin and Wound Assessment and Treatment Team of Calgary Home Care, Calgary Health Region, Calgary, Alberta. Ms. Gorst is a Physical Therapist, Ms. Bagg an Occupational Therapist and both Ms. Albert and Ms. Couture are Registered Nurses. The Urgency Tool was a selective for the completion of the University of Toronto International Interdisciplinary Wound Care Course (IIWCC 2002). Please address all correspondence to Richelle Gorst at rgorst@shaw.ca.

A deteriorating wound can be of great emotional, physical and financial cost to the client as well as the health-care system, and a timely wound-care referral to a knowledgeable health-care professional is vital. Though basic understanding of local wound care principles1,2 is necessary for all health-care professionals, Calgary Home Care has an interdisciplinary group of health-care professionals known as the Skin and Wound Assessment and Treatment (SWAT) Team that is responsible for expert-level wound-care consultation. A process is required to assist the practitioner in recognizing when the wound is not progressing toward healing as expected and when further intervention is required.

In an effort to provide timely care to clients at greatest risk, a new referral process, highlighted by an Urgency Tool, was developed. This new tool was designed to direct health-care professionals in determining appropriate wound care management, and to ensure referrals to the SWAT Team were made according to assessed need. The SWAT Team member receiving the referral is able to review the client’s wound status and consider the presence of a more complex type of wound requiring a higher level of care.

Table 1: Modified VIP Paradigm3

Vascular – Healability

  • Considers aspects related to the healability of the wound
  • Considers aspects related to vascular compromise

Infection – Wound Bed Assessment

  • Considers aspects related to the wound
  • Considers local wound-care principles for wound-bed preparation (moisture balance, bacterial balance and debridement)

Pressure – Cause(s)

  • Considers aspects related to the cause(s) of the presenting problem at many different levels

The Urgency Tool is a comprehensive form, divided into three main categories that incorporate an interdisciplinary approach to wound care. Each category of Vascular, Infection, and Pressure (VIP)1,3 has been adapted from the original paradigm to outline key risk factors that focus and guide the assessor toward completing a comprehensive wound-care referral to the SWAT Team. This ensures all integral categories related to healability, wound-bed assessment, and the cause(s) of the presenting problem have been considered prior to initiating a referral to the SWAT Team (see Table 1). Each applicable risk factor and the reason for referral are given their own weighted value. These are then totaled to provide the SWAT Team with valuable information concerning the client’s health status as well as a numerical score directly related to the urgency of the referral.

The Vascular category provides an efficient method for screening healability. The Tool enables the practitioner to focus on relevant subjective and objective symptoms that may indicate some form of vascular compromise or other factors that determine healability1,4,5. If the ulcer presents on the lower leg, information gathered through key factors such as night pain, rest pain and purple feet on dependency may point to decreased arterial circulation5,6—whereas visual skin changes such as woody fibrosis and hyperpigmentation may indicate chronic venous insufficiency5,6. Healability may extend beyond vascular assessment. The practitioner must recognize the impact of co-existing diseases such as anemia and/or cancers and systemic agents like medications and treatments that may impair healing6,7. Questions related to edema levels, history of DVT and previous leg ulcers assist in completing the overall picture and provide the SWAT Team members further guidance as to the urgency of the requested assessment. The information gathered acts as a guide for further investigation and must be combined with adequate history-taking and a detailed physical examination.

The Infection category, an intricate part of the Tool, prompts the clinician to assess the wound bed and its environment for infection. It is well known that optimal wound-bed preparation sets the stage for healing to occur1. Therefore, a thorough evaluation of the wound bed is vital to achieving balance within the wound environment. Key features assisting in this process (identified within the PSST* Tool) that may indicate a wound infection include an increase or change in the wound drainage and size of the wound; an increase in wound pain with swelling; heat and redness in the area surrounding the wound; and an increase of necrosis and friability of the tissues8,9,10,11. These points enable the assessor to recognize that a higher number of risk factors present means a more urgent referral to the SWAT Team is necessary.

The Pressure category presents key risk factors that are primarily, but not exclusively, based on components within the Braden Risk Assessment Tool12,13,14. Potential causes contributing to the presenting problem are identified and provisions can be made toward removing or modifying these risk factors. Areas relating to sensory perception, exposure to moisture, activity and mobility levels, nutrition and emotional well-being are explored. Individually or combined, the presence of these risk factors can increase the necessity and urgency of a referral to the SWAT Team.

Effective utilization of resources, balanced by appropriate patient care, are goals all health-care organizations strive to achieve. Policies, procedures and tools designed to facilitate this process can benefit all. The Urgency Tool aims to accomplish those goals, by providing the assessor with a comprehensive framework to evaluate the client at risk and the SWAT Team members with the information necessary to determine the urgency of the requested referral.

Downloadable example of SWAT Team Urgency Tool (PDF)

The Urgency Tool:

  • considers healability, wound-bed preparation and cause(s) of the presenting problem
  • enables consistent SWAT referrals across the program
  • encourages an interdisciplinary approach
  • facilitates timely referrals
  • provides an objective measure of urgency


References

  1. Sibbald RG et al. Preparing the wound bed – debridement, bacterial balance and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
  2. Keast DH, Orsted H. The basic principles of wound care. Ostomy/Wound Management. 1998;44(8):24-31.
  3. Inlow S, Orsted H, Sibbald RG. Best practice for the prevention, diagnosis, and treatment of diabetic foot ulcers. Ostomy/Wound Management. 2000;46(11):55-68.
  4. Krasner D, Sibbald RG. Wound management: best chronic wound care practices for the hyperbaric patient. In Hyperbaric Medicine Practice, Second Edition. Flagstaff AZ: Best Publishing Company. 1999:395-429.
  5. Kunimoto B et al. Best practices for the prevention and treatment of venous leg ulcers. Ostomy/Wound Management. 2001;47(2):34-46,48-50.
  6. Lazarus GS et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Rep Reg. 1994;2:165-70.
  7. Stotts N. Cofactors in impaired wound healing. In Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, PA. Health Management Publications, Inc. 2001:265-272.
  8. Dow G. Infection in chronic wounds. In Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, PA. Health Management Publications, Inc. 2001:343-356.
  9. Cutting KF, Harding KGH. Criteria for identifying wound infection. Journal of Wound Care. 1994;3(4):198-201
  10. Thomson PD, Toddonio TE. Wound infection. In Krasner D, Kane D. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Second Edition. Wayne, PA. Health Management Publications, Inc. 1997:84-89.
  11. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nursing Research. 1987;36(4):205-210.
  12. Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Adv Wound Care. 1997;10(5):65-73.
  13. Bates-Jensen BM. Indices to include in wound healing assessment.Adv Wound Care. 1995;8(4):suppl 25-33.
  14. Dolynchuk K et al. Best Practices for the prevention and treatment of pressure ulcers. Ostomy/Wound Management. 2000;46(11):38-51.

Back to top

   .
It is true that time is of the essence in health care. It is also vital that the right care is not only provided at the right time, but also by the right clinician.
   

Please contact us at: WCCeditor@cawc.net.

© CAWC 2003
Last modified: November 4, 2003