Wound Healing and Skin Integrity

Principles and Practice

Madeleine Flanagan

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN: 9780470659779
• eBook ISBN: 9781118442067
• Edition: 1
• Topic: Medicine
• Subtopic: Clinical Medicine

This comprehensive text integrates related aspects of wound management, skin integrity and dermatology into a convenient, one-stop resource. It explores the theories underpinning wound management and skin integrity by reviewing the supporting evidence and making practical recommendations for busy clinicians. Wound Healing and Skin Integrity discusses current and future trends in the management of wounds and maintenance of skin integrity in respect to international healthcare initiatives and summarises the principles of maintaining healthy skin to provide a practical guide that is accessible to clinicians regardless of professional background.

The title fulfils the inter-professional learning agenda and will be of interest to a wide range of clinicians, including doctors; wound management, dermatology and palliative care nurse specialists; community nurses; podiatrists; pharmacists; and anyone responsible for managing patients with impaired skin integrity.

Key features:

• A practical, accessible, evidence-based manual on wound care and skin integrity
• Integrates related aspects of skin integrity, wound management and dermatology previously found in separate texts into one comprehensive resource
• Written from a broad international perspective with contributions from key international opinion leaders from Australia, UK, Canada and Europe
• Promotes international practice development in relation to management of skin integrity and chronic wounds
• Full colour illustrations throughout
• Defines key terms, relates anatomy and physiology to clinical practice and provides a summary of easily accessible online learning resources 
• Includes practical tips from expert practitioners, commonly presented clinical queries and discussion of professional issues related to skin integrity

Section 1

Principles of Best Practice

1

Evidence and Clinical Decision-making

Carolina Weller

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

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Overview

• Evidence-based practice integrates the best available research evidence with information about patient preferences, clinician skills and available resources to make decisions about patient care.
• Barriers to the use of research-based evidence can occur when time, access to the literature, search skills, critical appraisal skills and implementation skills are lacking.
• Evidence-based clinical decision-making requires comparison of all relevant sources. In the absence of randomised controlled trials involving a direct comparison of treatments of interest, indirect treatment comparisons and systematic reviews provide useful evidence.
• Clinical guidelines appear to be one of the most effective methods of applying evidence to improve quality of care but little is known about the best way to implement them into everyday practice.
• Selective reading of high-quality evidence is one of the most effective strategies to improve research dissemination and changes in practice. There are now good sources of evidence-based information available on the Internet that help identify, appraise and apply research findings to clinical practice.

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Introduction: what is effective clinical decision-making?

Clinical decision-making is an essential part of effective wound management and is based on clinical judgement which consists of professional performance and human judgement. Health care providers increasingly recognise the importance of making decisions based on the best possible evidence. Making decisions that will impact on the healing outcome of individuals in the clinical workplace take place every day but reliability of clinical judgement is often variable as many different factors will influence decisions; these include the type of clinical setting, interpersonal relationships, available diagnostic data, scope of practice and individual skill (DiCenso et al., 2010). The process of clinical decision-making should ideally include use of research findings, clinical guidelines, and evidence-based treatment algorithms (Rose, 2011). Improving the implementation of evidence-based practice (EBP) and public health depends on behaviour change. Health care outcomes such as choice of type of compression to encourage patient adherence to compression therapy are often based on decisions made within an organisation, which adds another layer of complexity to clinical decision-making. Clinical decisions that impact directly on patient safety and quality of care are made by health professionals based on previous knowledge and experience. The care received by patients in relation to wound care is often dependent on factors that are related to characteristics of individual health professionals, such as education and training in wound care as well as behaviour of people in the workplace (Grol, 2002). For patients to benefit from treatment, clinicians must have a mastery of skills, including history-taking and physical examination, although effective clinical decision-making does not begin or end there, continuous, self-directed lifelong learning is paramount to advance wound management and improve quality of care.

What is evidence-based health care?

Best practice research evidence refers to methodologically sound, clinically relevant research about the effectiveness and safety of interventions, the accuracy and precision of assessment measures, the power of prognostic indicators, the strength of causal relationships, the cost-effectiveness of interventions and the meaning of illness or patient experiences (Sackett et al., 1996).

Over 10 years ago, the Cochrane systematic reviews (Cullum et al., 2000; O’Meara et al., 2009) reported the importance of multi-component compression bandages to heal people with venous leg ulcers (VLUs) and the importance of Ankle Brachial Pressure Index (ABPI) assessment to exclude arterial disease prior to compression application. This type of evidence should guide clinical practice, but what if the clinician does not have access to a hand-held Doppler and is unable to refer to a vascular laboratory or specialist wound clinic due to geographical or cost factors? Even if a Doppler is available the clinician may not have the confidence to assess the patients and measure the ABPI as found in a recent cross-sectional survey of practice nurses (PNs) working in Australian general practice clinics. This study identified that knowledge of VLU management was sub-optimal and current practice did not comply with evidence-based VLU management guidelines (Weller and Evans, 2012). Despite recognition by PNs that specialist wound clinics provide a valuable resource, more than 40% did not refer patients for treatment and a third retained patients for over 3 months before referring them for specialist assessment. In the United Kingdom, PNs typically have sole responsibility for determining the patient’s treatment plan (Ertl, 1992; McGuckin and Kerstein, 1998). Despite 70% of PNs having some responsibility for determining VLU management, less than 20% stated that they used best practice guidelines to direct treatment (Weller and Evans, 2012).

Despite availability of evidence to support leg ulcer management, studies have identified deficiencies in general practice management of leg ulceration, specifically the under-use of ABPI measurements, over-reliance on dressings and lack of understanding of compression therapy (McGuckin and Kerstein, 1998; Graham et al., 2003; Sadler et al., 2006).

Research evidence alone is never sufficient to make a clinical decision. Clinicians often weigh up the benefits and risks, inconvenience and costs associated with alternative management strategies, and in doing so consider the patient’s values. Patient values and preferences refer to the underlying assumptions and beliefs that are involved when clinicians, together with patients, weigh what they will gain making a clinical management decision such as choosing a compression system that is easy for the nurse to apply, is less expensive and is more comfortable for the patient. Healing time can be improved simply by addressing the issue of nurse application, patient adherence and cost-effectiveness (Weller et al., 2010b, 2010c). EBP involves the incorporation of research evidence, clinical expertise and client values in clinical decision-making (Sackett et al., 1996). Application of high-quality evidence to clinical decision-making requires knowledge of how to access evidence in the first place; includes an understanding of literature searching and application of critical appraisal skills to differentiate lower- from higher-quality clinical studies (Weller, 2009).

Common misperceptions about evidence-based practice

• Clinicians believe they already ‘do’ EBP;
• EBP is a passing trend;
• EBP leads to ‘cook book’ medicine;
• EBP is expensive and time-consuming;
• EBP is a restriction of clinical freedom;
• ‘I have always done it this way, so I know it works’.

How does evidence fit into clinical decision-making in clinical practice?

The skills necessary to provide an evidence-based solution to a clinical problem includes several aspects such as defining the problem, conducting an efficient search to locate the best evidence, critically appraising the evidence and considering that evidence and its implications in the context of patients’ circumstances and values (Box 1.1).

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Box 1.1 Steps for appraising the literature

1. Ask an answerable question from a clinical issue

PICOT is one technique that can used to develop clinical research questions. PICOT is an acronym for the five different areas the technique considers: patient/population, intervention or issue, comparison with another intervention or issue, outcome and timeframe; e.g. Which interventions help people adhere to compression therapies for venous leg ulceration?

2. Search for valid external evidence

Quick access to pre-appraised information is available at

• The Cochrane Library
• PubMed Clinical Queries
• ACP Journal Club
• Evidence-based Medicine

3. Critically appraise the evidence for relevance and validity

Methods

Consider

• Study design, e.g. randomised controlled trial, cohort study, survey;
• Clinical setting, e.g. hospital, community;
• Patient population, e.g. sample size, inclusion/exclusion criteria;
• Describe intervention group and control group;
• Blinding (if applicable), e.g. double blind, single blind;
• Statistical analysis, e.g. suitability of tests;
• Relevance of outcome measures, e.g. time to complete healing;
• Follow-up, e.g. duration, all patients accounted for.

Results

Consider

• Relevance of outcomes, e.g. number needed to treat, sensitivity, specificity;
• Time points of reporting;
• Compliance with intervention/therapy/medications;
• Adverse effects.

4. Apply the results back to the patient

There is low-quality evidence that leg ulcer clinical care may not improve adherence to compression therapy or healing rates or prevent recurrence when compared to home care. Because of the lack of reliable evidence, it is not possible to recommend nurse clinical care interventions. There is a need to improve and increase interaction with patients emphasising the adherence in future compression...

Table of contents

• Cover
• Title Page
• Copyright
• List of Contributors
• Preface
• Acknowledgements
• Section 1: Principles of Best Practice
• Section 2: Challenging Wounds
• Section 3: Improving Skin Integrity Services
• Index