Evidence-based wound care in the UK

Evidence generation for wound care dressing selection: reviewing the issues

In the UK, dressings are categorised as medical devices and manufacturers only have to provide limited evidence of effectiveness before dressings are used in clinical practice. Therefore, evidence based on clinical trial methods is scant. As a direct result, governing bodies in the UK are now recommending that decisions to select one dressing over another could mainly be made on price. Placed within the movement critiquing evidence-based practice (EBP), this paper summarises the main issues surrounding the generation of evidence in selecting dressings for wound care, which is immersed in a context that lacks resources, legislative clarity and freedom to choose methodological alternatives. Dressings are therapeutic medical devices rather than consumables and any rationalisation based on costs may have far-reaching implications for wound care clinicians through purchasing decisions and thus may limit their ability to manage wounds effectively.

Viewing dressing evaluation through a pragmatic lens: The application of Dewey's experimentalism in the development of evidence for dressing selection

RATIONALE, AIMS, AND OBJECTIVES

The aim of this paper is to (1) summarize the challenges with developing evidence for dressing selection in wound care, (2) discuss the limiting influence that the Evidence-Based Practice movement has had in this field, and (3) discuss the opportunities offered by Dewey's theory of experimentalism as a pragmatic solution to develop a structured body of evidence.

FINDINGS

Whilst the number of dressings available on the market continue to proliferate, limited progress has taken place to develop a methodology for dressing evaluation that is relevant to clinical practice. It is proposed that experimentalism can be operationalized with a mixed-methods approach that may include the following: (1) medical histories and patient's stories; (2) participant observation and informal interviews; (3) a comparative study between a new dressing and standard care; (4) a patient's satisfaction survey; (5) a staff survey; (6) a cost examination; (7) an evaluation of the packaging and procurement route; and finally (8) a clinical meeting to triangulate the data and reach a consensus.

CONCLUSION

Experimentalism offers a framework for the construction of evidence used for dressing selection. Central to this concept is the integration of experience to the data collected. The context of the evaluation has equal weight to the data thus collected.

A national survey by the SDMA: use of evidence in nursing practice

OBJECTIVE

Recently, two surveys were conducted by the Surgical Dressing Manufacturers Association (SDMA) to investigate the evidence required to support wound care products. These showed very clearly that industry provides significant amounts of evidence in a way that appears to meet the expectations of relevant health professionals and their practice for treating patients with wounds. The responses of health professionals refuted the opinion that evidence may be lacking for wound care products. Hopefully, the results of these surveys also add weight to the argument that the Cochrane Review approach is not always the most appropriate for wound care-where the comorbidities of patients are variable and often plural.

Wound assessment tools and nurses' needs: an evaluation study

The purpose of this study was to ascertain how well different wound assessment tools meet the needs of nurses in carrying out general wound assessment and whether current tools are fit for purpose. The methodology employed was evaluation research. In order to conduct the evaluation, a literature review was undertaken to identify the criteria of an optimal wound assessment tool which would meet nurses' needs. Several freely available wound assessment tools were selected based on predetermined inclusion and exclusion criteria and an audit tool was developed to evaluate the selected tools based on how well they met the criteria of the optimal wound assessment tool. The results provide a measure of how well the selected wound assessment tools meet the criteria of the optimal wound assessment tool. No tool was identified which fulfilled all the criteria, but two (the Applied Wound Management tool and the National Wound Assessment Form) met the most criteria of the optimal tool and were therefore considered to best meet nurses' needs in wound assessment. The study provides a mechanism for the appraisal of wound assessment tools using a set of optimal criteria which could aid practitioners in their search for the best wound assessment tool.

Assessment and documentation of non-healing, chronic wounds in inpatient health care facilities in the Czech Republic: an evaluation study

The foundation of health care management of patients with non-healing, chronic wounds needs accurate evaluation followed by the selection of an appropriate therapeutic strategy. Assessment of non-healing, chronic wounds in clinical practice in the Czech Republic is not standardised. The aim of this study was to analyse the methods being used to assess non-healing, chronic wounds in inpatient facilities in the Czech Republic. The research was carried out at 77 inpatient medical facilities (8 university/faculty hospitals, 63 hospitals and 6 long- term hospitals) across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The results of this research have corroborated the suspicion of inconsistencies in procedures used by general nurses for assessment of non-healing, chronic wounds. However, the situation was found to be more positive with regard to evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of a wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were significantly improved when a consultant for wound healing was present (P = 0·047). The same applied to facilities possessing a certificate of quality issued by the Czech Wound Management Association (P = 0·010). In conclusion, an effective strategy for wound management depends on the method and scope of the assessment of non-healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of a 'non-healing, chronic wound assessment' algorithm.

Fundamentals of randomized clinical trials in wound care: reporting standards

In wound care research, available high-level evidence according to the evidence pyramid is rare, and is threatened by a poor study design and reporting. Without comprehensive and transparent reporting, readers will not be able to assess the strengths and limitations of the research performed. Randomized clinical trials (RCTs) are universally acknowledged as the study design of choice for comparing treatment effects. To give high-level evidence the appreciation it deserves in wound care, we propose a step-by-step reporting standard for comprehensive and transparent reporting of RCTs in wound care. Critical reporting issues (e.g., wound care terminology, blinding, predefined outcome measures, and a priori sample size calculation) and wound-specific barriers (e.g., large diversity of etiologies and comorbidities of patients with wounds) that may prevent uniform implementation of reporting standards in wound care research are addressed in this article. The proposed reporting standards can be used as guidance for authors who write their RCT, as well as for peer reviewers of journals. Endorsement and application of these reporting standards may help achieve a higher standard of evidence and allow meta-analysis of reported wound care data. The ultimate goal is to help wound care professionals make better decisions for their patients in clinical practice.

The use of biatain Ag in hard-to-heal venous leg ulcers: meta-analysis of randomised controlled trials

Background

Venous leg ulcers are common, troublesome, and their failure to heal is often related to a heavy bio-burden. Ionized silver has both anti-inflammatory and antimicrobial properties. The ulcer healing properties of the silver releasing foam dressing Biatain Ag has been examined in 4 randomized controlled trials (RCTs).

Aim

To evaluate ulcer healing through a meta-analytic approach after treatment with either Biatain Ag or a non-active dressing.

Patients and Methods

685 subjects with pure or mixed hard-to-heal venous leg ulcers were included in the meta-analysis.

Results

Biatain Ag showed a significant treatment effect (p<0.0001), responder rate (p<0.001), and healing rate (p = 0.002).

Conclusion

The meta-analysis of the 4 RCTs provided statistical significant evidence to support the use of Biatain Ag dressing in treatment of hard-to-heal venous leg ulcers.

Does evidence permeate all surgical areas equally? Publication trends in wound care compared to breast cancer care: a longitudinal trend analysis

BACKGROUND

Evidence-based decision making has permeated the daily practice of healthcare professionals. However, in wound care this seems more difficult than in other medical areas, such as breast cancer, which has a similar incidence, variety of etiologies, financial burden, and diversity of treatment options. This incongruence could be due to a lack in quantity and quality of available evidence. We therefore compared worldwide publication trends to answer whether research in wound care lags behind that in breast cancer.

METHODS

In order to assess the trends in quantity and methodological quality of publications as to wound care and breast cancer treatments, we examined relevant publications over the last five decades. Publications in MEDLINE were classified into seven study design categories: (1) guidelines, (2) systematic reviews (SR), (3) randomized (RCT), and controlled clinical trials (CCT), (4) cohort studies, (5) case-control studies, (6) case series and case reports, and (7) other publications.

RESULTS

We found a 30-fold rise in publications on wound care, versus a 70-fold increase in those on breast cancer. High-quality study designs like SR, RCT, or CCT were less frequent in wound care (difference 1.9, 95 % CI 1.8-2.0 %) as were guidelines; 76 on wound care versus 231 for breast cancer.

CONCLUSIONS

Publications on wound care fall behind in quantity and quality as compared to breast cancer. Nevertheless, SR, RCT, and CCT in wound care are becoming more numerous. These high-quality study designs could motivate clinicians to make evidence-based decisions and researchers to perform proper research in wound care.

Evidence-based decisions for local and systemic wound care

Background

Decisions on local and systemic wound treatment vary among surgeons and are frequently based on expert opinion. The aim of this meta-review was to compile best available evidence from systematic reviews in order to formulate conclusions to support evidence-based decisions in clinical practice.

Methods

All Cochrane systematic reviews (CSRs), published by the Cochrane Wounds and Peripheral Vascular Diseases Groups, and that investigated therapeutic and preventive interventions, were searched in the Cochrane Database up to June 2011. Two investigators independently categorized each intervention into five levels of evidence of effect, based on size and homogeneity, and the effect size of the outcomes.

Results

After screening 149 CSRs, 44 relevant reviews were included. These contained 109 evidence-based conclusions: 30 on venous ulcers, 30 on acute wounds, 15 on pressure ulcers, 14 on diabetic ulcers, 12 on arterial ulcers and eight on miscellaneous chronic wounds. Strong conclusions could be drawn regarding the effectiveness of: therapeutic ultrasonography, mattresses, cleansing methods, closure of surgical wounds, honey, antibiotic prophylaxis, compression, lidocaine–prilocaine cream, skin grafting, antiseptics, pentoxifylline, debridement, hyperbaric oxygen therapy, granulocyte colony-stimulating factors, prostanoids and spinal cord stimulation.

Conclusion

For some wound care interventions, robust evidence exists upon which clinical decisions should be based.

Do stakeholders in wound care prefer evidence-based wound care products? A survey in the Netherlands

For several wound products compelling evidence is available on their effectiveness, for example, from systematic reviews. The process of buying, prescribing and applying wound materials involve many stakeholders, who may not be aware of this evidence, although this is essential for uniform and optimum treatment choice. In this survey, we determined the general awareness and use of evidence, based on (Cochrane) systematic reviews, for wound products in open wounds and burns among wound care stakeholders, including doctors, nurses, buyers, pharmacologists and manufacturers. We included 262 stakeholders. Doctors preferred conventional antiseptics (e.g. iodine), while specialised nurses and manufacturers favoured popular products (e.g. silver). Most stakeholders considered silver-containing products as evidence-based effective antiseptics. These were mostly used by specialised nurses (47/57; 82%), although only few of them (9/55; 16%) thought using silver is evidence-based. For burns, silver sulfadiazine and hydrofibre were most popular. The majority of professionals considered using silver sulfadiazine to be evidence-based, which contradicts scientific results. Awareness and use of the Cochrane Library was lower among nurses than among doctors (P < 0.001). Two thirds of the manufacturers were unaware of, or never used, the Cochrane Library. Available compelling evidence in wound care is not equally internalised by stakeholders, which is required to ensure evidence-based decision making.

Antimicrobial sutures and prevention of surgical site infection: assessment of the safety of the antiseptic triclosan

This article is based on a second Hygienist Panel meeting held in London on 16-17 June 2010. The Panel discussed the current use of antimicrobials and care bundles in the prevention of surgical site infection; the need to comply with good antibiotic stewardship, to reduce the risk of antibiotic-resistant and emergent organisms; and the need to revisit the use of antiseptics. The discussion was driven by concerns of the use of triclosan, which had been raised by a publication from the Scientific Committee on Consumer Products of the Directorate General for Health and Consumers, European Commission. Uncertainties that excessive use of triclosan for preservation and in cosmetics could select naturally resistant environmental organisms or induce reduced triclosan-susceptibility or antibiotic resistance were considered. It was concluded that the uses of triclosan with demonstrable health benefits, as in some medical applications (such as antimicrobial sutures), need to be distinguished from those where there is no proven benefit, such as its use in certain consumer products. The addition of triclosan to a product must be substantiated in any claim of preventive or therapeutic health benefit. Triclosan is the most widely studied biocide and this same level of information should be available for other topically used antimicrobials, which are widely used in surgical practice and chronic wound care.

French national wound management survey: choice criteria of dressings

Across Europe, wound care management is organized differently, and in some countries such as the UK or Denmark, wound healing centres have been implemented. In France, a large number of health professionals are not sufficiently educated in wound care management during their vocational training. The rapid evolution of dressings has changed wound management practices and has given rise to new professional recommendations. This national survey was carried out in France in 2009, including 465 health professionals, to determine the criteria they use to choose a dressing and their habits of care with acute or chronic wounds. Around 73% of respondents were nurses and, on average, participants took care of 43 wounds per month. It was also found that 89% of the health professionals who took part prefer the sequential treatment of the wound based on its appearance. Regardless of whether the wound is acute or chronic, the priorities for wound care and the choice of dressing are the management of the exudate and the prevention or treatment of infection. These results put into evidence the adequacy of the recommendations by these practitioners and the good correlation between the choice of dressing and the local therapeutic goal. To reach the same level of expertise, the professional training for health professionals who are less frequently involved in wound care is necessary.

An overview of the evidence on the efficacy of silver dressings

While there is a plethora of clinical and anecdotal evidence on the efficacy of silver dressings, there is no rigorous RCT data to support this. This has led procurement managers to defer the inclusion of silver dressings on wound formularies, despite its clinical popularity. This article gives an overview of the evidence on topical antimicrobials, in order to determine whether there is a case for such a stance.