Transcript Education and Research Opportunities from a Content
Research and Education Opportunities From a Content-Validated, Evidence Based Pressure Ulcer Guideline
NPUAP Las Vegas, NV, February 25-26, 2011 Presented on Behalf of AAWC Guideline Department And NAWCC Research, Education Collaborators Laura Bolton, PhD, Adj. Assoc. Professor Surgery (Bioengineering), Robert Wood Johnson Univ. Medical School, New Brunswick, NJ, USA E-mail: [email protected]
©Association for the Advancement of Wound Care 2011
Collaborating Contributors
Guideline Developers from the AAWC 1 Guideline Department
• • • • • • • • • • • • Co-chairs: Laura Bolton, Ph.D. and Susan Girolami, RN, BSN, CWOCN Mona Baharestani PhD ANP, CWOCN CWS Teri Berger, RN, CWCN DeSales Foster MSN, CWOCN, CRNP, GNP-BC Linda Foster, RN, BSN, CWCN Roslyn Jordan, RN, BSN, CWOCN Sofia Kahn, MD, MBBS, M Gen. Surgery Diane Merkle, APRN, CWOCN Patrick McNees, PhD, FAAN Laurie Rappl, PT Stephanie Slayton, PT, DPT, CWS Jeremy Tamir, MD FAPWCA Kathy T. Whittington, RN, MS, CWCN
Collaborating Research and Education Evaluators 2
• Association for the Advancement of Wound Care (AAWC): Sue Girolami, RN, BSN, CWOCN, Laura Bolton, PhD • Canadian Assoc. for Enterostomal Therapy (CAET): Mary Hill, RN, BScN, MN, CETN(C) • Canadian Association of Wound Care (CAWC): M. Gail Woodbury, PhD, MAPWCA • Mexican Wound Healing Association (AMCICHAC): Jose Contreras-Ruiz, MD • National Pressure Ulcer Advisory Panel (NPUAP): Joyce Black PhD, RN, CPSN, CWCN • Wound Healing Society (WHS): Joie Whitney, PhD, RN, CWCN, FAAN and Laura Bolton, PhD 1. Association for the Advancement of Wound Care 2. From North American Wound Care Council (NAWCC) Organizations
Purpose / Continuing Education Objectives Highlight PU Research & Education Needs
• • • Describe how to unify pressure ulcer guidelines using content validity and best available evidence Identify good evidence that is not believed: educational opportunities Recognize widely held opinions that need research to find if they work and are safe
Rationale: Evidence-Based Care Works To Prevent Pressure Ulcers Percent Pressure Ulcer Incidence Per Month Pre-Protocol Protocol (5 mo) LTC 110 Bed Center B Reduced PU Incidence 75% Pre-protocol vs Protocol p = 0.02
15 3.5
LTC 150 Bed Center A Reduced PU Incidence 87% 1.7
13.2
Lyder C
et al. Ostomy / Wound Management
2002; 48(4):52-62.
Rationale: Evidence-Based Care Works To Heal Pressure Ulcers:
In Home Telemedicine More Wounds Healed Faster With Fewer Visits Kobza L, Scheurich A.
Ostomy/Wound Management 2000;
46(10):48-53
Rationale
: Real-World Evidence-Based Care 1 Predicts 12-week Pressure Ulcer Healing Settings: Home, Acute, Long Term Care 2,3 Full-thickness PU take twice as long to heal as partial thickness do 2 . Prevent PU! Act early to heal them!
Stage 4 Heel Pressure Ulcer Courtesy la4seniors.com
Predictors of Healing 3 Area < 3.4 cm 2 (p<0.0001) Partial-thickness(p<0.0001) Unknown depth (p=0.02) Hydrocolloid or fiber use (p=0.02) Depth: Thickness Mean + SE heal time % Healed in 12 weeks Partial (N = 134) 31 + 5 days 61% Full (N = 373) 62 + 4 days 36% 1 . Solutions® Algorithms of Wound Care, www.guidelines.gov
2. Bolton L , McNees P, van Rijswijk et al, JWOCN, 2004; ; 31(3):65-71 3. Smitten A, Bolton L Adv Skin WC, 2005; 18(4):192-193.
• •
Rationale:
1
Improve Pressure Ulcer Outcomes!
Professionals confused. PU guidelines differ in: – Scope, definitions, validation, evidence criteria, procedures recommended – Recommendations for risk assessment, diagnosis, prevention, treatment and outcome measures.
Improve consistency, quality of PU care. Inform! – Strength of Evidence > Strength of Opinion: Educate! – Strength of Opinion > Strength of Evidence: Research! – Strong Evidence and Opinion: Implement! 1 Bolton LL, Girolami S, Slayton S, et al. Assessing the need for developing a comprehensive content-validated pressure ulcer guideline.
Ostomy / Wound Management
2008; 54(11):22-30.
• • •
Methods
1
: Guideline Development
Timeline: January, 2008 - February, 2009 – 12 Guidelines and literature searches: Jan-Oct, 08 – – Compile, simplify recommendations: Feb-Nov 08 Content validate recommendations: Nov 08-Feb 09 – MEDLINE derived best evidence: Feb 08-Feb 11 Funding AAWC only: annual meeting; monthly teleconferences Volunteer Interdisciplinary AAWC Guideline Dept – 4 CWOCN, 3 CWCN, 2 MD, 1 PT, 1 PT PhD, 2 PhD 1 Bolton LL, Girolami S, Slayton S, et al. Assessing the need for developing a comprehensive content-validated pressure ulcer guideline.
Ostomy Wound Management
2008; 54(11):22-30.
• • • •
Methods
: Content Validation by Online Survey
Dec 2008-Feb 2009—Nov 2009 invitation to: – 20,000 Ostomy/Wound Management readers – 1700 AAWC members 31 Multidisciplinary Respondents : Degrees
PT CWOCN RN APN MD PhD
6 15 11 6 3 Rated all 368 recommendations : 2 1 = Not clinically relevant 2 = Too confusing to decide
3 = Clinically relevant, need to improve
4 = Clinically relevant and succinct
Content Validity Index > 0.75 validated opinion
Methods:
Evidence Source & Criteria
• •
Evidence Sources: MEDLINE, EMBASE AHRQ (former AHCPR) evidence criteria
– Level A: Efficacy: > 2 human pressure ulcer RCTs Diagnostic/screening: > 2 PU cohorts validate – Level B: 1 RCT plus > 1 PU non-random CTs – Level C: < 2 controlled trials; opinion, case series
Methods: Collaborating Organization NAWCC Research and Education Evaluators Association for the Advancement of Wound Care (AAWC): • Sue Girolami , RN, BSN, CWOCN, Laura Bolton, PhD Canadian Association for Enterostomal Therapy (CAET): • Mary Hill, RN, BScN, MN, CETN(C) Canadian Association of Wound Care (CAWC): • M. Gail Woodbury, PhD, MAPWCA National Pressure Ulcer Advisory Panel (NPUAP): • Joyce Black 1 PhD, RN, CPSN, CWCN Wound Healing Society (WHS): • Joie Whitney, PhD, RN, CWCN, FAAN, Laura Bolton, PhD • AMCICHAC (Mexican Wound Healing Association: • Jose Contreras-Ruiz, MD, Former President of AMCICHAC
Methods:
Research & Education Evaluation
Each evaluator analyzed a portion of the 368 content-validated, evidence-linked recommendations using criteria in Table 1.
Table 1. Criteria for Research and Education Opportunities Level of Evidence and Content Validity Research or Education Opportunities A Level Evidence + CVI value > 0.75 Strong evidence & validity: Ready for implementation 0.75 Strong content validity only: Research Opportunity A Level evidence + CVI value < 0.75 Strong evidence only: Education Opportunity
Results:
Content Validity Survey Multidisciplinary Respondents
• • • Gender: 26 female, 5 male Settings: acute, chronic, home or office Professional credentials 20 Nurse professionals 10 WOCNs, 1 NP, 1 CWCN 6 Physical Therapists 3 Physicians Specialties: Physiatrist, Plastic Surgeon, Podiatrist 2 Ph D researchers
Results:
More Belief Than Evidence (N = 368 Recommendations)
26.4% N = 97 Level A Level B Level C 63.0
N = 232 10,6% N = 39
Results
: Content Validity and Evidence More Research than Education “Ops”
Not ready for PU use
Level C Evidence Level Level B Level A 4,9% 0,0% 1,9%
Evidence without belief: Educate!
58,2%
Belief with weak evidence 68.8%: Research!
10,6%
Ready for PU use
24,5%
Results:
1.9% Evidence without belief: Educate!
• •
Patient/pressure ulcer assessment
Patient body mass index Culture/ethnicity How to measure ulcer length, width
Pressure ulcer treatment
Enzymatic debridement Hydrocolloid dressing use, Monochromatic light stimulation
Results:
68.8% Belief, weak evidence: Research!
•
Patient and pressure ulcer assessment
Physical exam Laboratory diagnostic testing Documenting skin condition Documenting response to treatment Documenting pressure ulcer stage Stage I Heel Pressure Ulcer (Source: Medscape)
Results:
68.8% Belief, weak evidence: Research!
•
Pressure ulcer prevention / prevent recurrence
Skin Inspection and maintenance: All aspects Nutrition, fluid intake, appetite stimulants for pressure ulcer prevention and treatment Mobility, exercise, positioning and pressure redistribution interventions and equipment Interdisciplinary approach, consults and educational interventions
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Results:
68.8% Belief, weak evidence: Research!
Pressure ulcer treatment
Preventive interventions, support surfaces and pressure redistribution devices Mechanical and surgical debridement All surgical interventions (e.g. closing or grafting) Antimicrobial cleansing or dressing products Filling ulcer dead space Hydrating ulcers or stabilizing temperature Preventing and managing pain and palliative care Compare advanced/adjunctive treatments to A-level non-gauze controls
Results:
4.9% Not Ready for PU Use:
Need Research and Education Before Considering Pressure Ulcer Use • •
Pressure ulcer assessment
Using halogen lamp to assess PU or anatomic length and width to assess ulcer area change
Pressure ulcer treatment
Surgical or sharp as the first choice of debridement, laser or pulsatile lavage debridement Topical phenytoin, estrogen or skin equivalents
Conclusions
• • • • Real-world evidence shows evidence-based care works.
AAWC “Guideline of Pressure Ulcer Guidelines” – Accessible at www.aawconline.org and at – – – National Guideline Clearinghouse www.guidelines.gov
Measured evidence and opinion strength Provides basis to identify research, education opportunities. – Unique guideline development process highlights what we know, don’t know and need to know.
Collaboration worked to find research/education needs – Members of AAWC, AMCICHAC , CAWC, CAET, NPUAP, WHS Much research and education are needed to improve pressure ulcer patient outcomes!