International projects to prevent chronic wounds - 20/09/2012
International Projects toPrevent Chronic Wounds Professor Carol Dealey
In this presentation• I will be talking about 3 different international projects in which I have been involved as useful examples• They have all been undertaken in a slightly different way• They all involve pressure ulcers
International Pressure Ulcer Guidelines• This project took over my life for 5 years!• It was very hard work, but very satisfying.• I made some good friends during this time• So – here is the story of how the guidelines were developed.
The Two Societies .EPUAP = European Pressure Ulcer NPUAP = National Pressure UlcerAdvisory Panel, founded in 1996 it Advisory Panel and it is anis a Pan-European Society American society founded in 1987
• Both associations had produced pressure ulcer guidelines: NPUAP in 1992 (Prevention) and 1994 (Treatment) EPUAP in 1997 (Prevention, 1998 (Treatment) and 2003 (Nutrition) There was an urgent need for these guidelines to be updated
When in doubt – form a committee!• Guideline development Group (GDG)– from both EPUAP and NPUAP• Carol Dealey – Chair EPUAP GDG• Janet Cuddigan & Diane Langemo – Co-Chairs of NPUAP GDG• 5 members from each society
Guideline Development Group European Pressure Ulcer Advisory Panel Dr. Carol Dealey Dr. Michael Clark, Dr. Lisette Schoonhoven, Anne Witherow, Prof. Dr. Tom Defloor, Dr. Katrien Vanderwee National Pressure Ulcer Advisory Panel Dr. Janet Cuddigan Dr. Diane K. Langemo Dr. Mona M. Baharestani Mary Ellen Posthauer Dr. Joyce Black Evan Call
• The full GDG (NPUAP and EPUAP) defined a search strategy for both guidelines.• Evidence was limited to papers published in peer-reviewed journals and cited on PubMed, CINAHL, EMBASE, AHMED or the Cochrane and HTA databases. Quantitative studies were included if they were laboratory-based studies, controlled or cohort studies.• The full GDG developed a template for all the evidence tables
• The full GDG agreed the hierarchy of evidence to be used in both guidelines• Each guideline was divided into a series of topics, recognising that there will be some overlap between the two.• The treatment guideline does not include all possible topics, but has assessed those most clinically useful
Strength of Evidence Rating for Strength of Evidence Recommendations• A – Recommendation supported by direct scientific evidence from properly designed & implemented controlled trials on PU in humans providing statistical results that consistently support the guideline statement. (Level I studies)• B – Recommendation supported by direct scientific evidence from properly designed & implemented clinical series on PU in humans providing statistical results that consistently support the recommendation. (Level II, III, IV, V studies)• C – The recommendation is supported by expert opinion or indirect evidence (e.g. surrogate outcomes, studies in animal models & other types of chronic wounds).
Reviewing the EvidenceSmall Working Groups (SWGs)• Sub-groups, each with a sub-group leader, reviewed the literature for specific topics• Evidence tables were produced, allowing the SWG to develop guideline statements and a summary of the evidence• Guideline statements and supporting text sent to GDG for review
• Draft recommendations then circulated to full GDG (NPUAP and EPUAP) for comments• The GDG met to agree format for the guideline document and review the draft recommendations in order to develop the 1st draft of the guideline topics• The topics were then made available for stakeholder review
Review• Every stakeholder was informed when the statements were available for review and given the opportunity to comment on the statements both by suggesting literature that might have been missed and commenting on the text• The full GDG met to discuss each comment and review the suggested literature• The guideline text was then revised in the light of the literature/comments as appropriate
Final Draft Stage• This stage was all about ensuring there were no anomalies between treatment and prevention• Checking the text for typos• Ensuring we had all the evidence tables• Checking and rechecking the references
The Guidelines werepublished in 2009They are available as aClinical Practice Guideand as Quick ReferenceGuidesThe QRG is available in18 different languagesincluding PortugueseThe translations arefreely available fordownload atwww.epuap.org
What did I learn about International collaboration?• It is really important to talk to each other – emails are not enough!• When we started the guidelines the 2 societies did not know each other well and there were misunderstandings at first. American English and English English are not the same!• Be prepared to compromise
A project to produce aconsensus document onpressure ulcer aetiology.It aimed to expand on theinformation in theInternational PressureUlcer Guidelines.Unlike the Guidelineswhich were funded byEPUAP and NPUAP, thiswas funded by anunrestricted educationalgrant from KCI EuropeHolding BV
Expert working group• Mona Baharestani*, (USA) • Maarten Lubbers*, (The• Netherlands) Joyce Black*, (USA) • Courtney Lyder*, (USA)• Keryln Carville, (Australia) • Takehiko Ohura, (Japan)• Michael Clark*, (UK) • Heather Orsted, (Canada)• Janet Cuddigan*, (USA) • Vinoth Ranganathan, (USA)• Carol Dealey*, (UK) • Steven Reger*, (USA)• Tom Defloor*, (Belgium) • Marco Romanelli*, (Italy)• Amit Gefen*, (Israel) • Hiromi Sanada, (Japan)• Keith Harding, (UK) • Makoto Takahashi, (Japan)• Nils Lahmann*, Berlin (Germany) * = worked on EPUAP/NPUAP Guidelines
Pressure, shear, friction and microclimate – why needed?• Pressure has long been viewed as the most important extrinsic factor in pressure ulcer development• Increasing interest in the roles of shear, friction and microclimate• Emerging awareness of the synergistic links between pressure, shear, friction and microclimate
Pressure, shear, friction and microclimateGroundbreaking initiative:• Fulfilled a need for educational materials that aid understanding of the basic physics involved in pressure, shear, friction and microclimate• Demonstrated how the physics involved underpins best clinical practice in the prevention (and treatment) of pressure ulcers
Pressure, shear, friction and microclimateThe technical section of each paper:• Defined the relevant extrinsic factor• Clearly described basic physics involved• Explained the contribution of the extrinsic factor to pressure ulcer aetiology• Described the links between the factors
Pressure, shear, friction and microclimateThe clinical practice section of each paper:• Described how to identify patients at risk from the extrinsic factor• Explained the types of and rationale for the clinical interventions that aim to prevent or ameliorate the effects of the extrinsic factorNote: Pressure ulcer prevention involves much more than extrinsic factor modification: this document was not intended to provide a comprehensive discussion of pressure ulcer prevention protocols
How did this project work?• This work was undertaken with a mixture of teleconferences and emails• The scientists wrote the physics part and some of the clinicians (mostly nurses) wrote the clinical application• It went out for review to the rest of the expert group
The OutcomeA useful documentfreely available todownload from theWounds Internationalwebsite:http://www.woundsinternational.com/pdf/content_8925.pdf
What did I learn from this project?• We need scientists to explain the physics• But they cannot apply this knowledge to clinical practice – that is where nurses come in.• So we need multi-professional working – and to respect each others’ expertise
There’s more• When you know each other it is easier to work at long distance• This project involved writing, reviewing and judicious editing and formatting (by Wounds International)• There did not need to be a lot of debate on the content
Global Evidence BasedPractice Recommendationsfor the Use of WoundDressings to AugmentPressure Ulcer PreventionProtocols - August 2012This is very new and nottotally completed, so I amgoing to tell you quite a bitabout itIt has been funded by aneducational grant fromMolnlycke Healthcare
Consensus groupJoyce Black RN PhD Michael Clark PhD Paulo Alves RN MSc Tod Brindle RN MSc(Co-Chair) (Co-Chair) Paulo Alves is an Assistant Professor Tod Brindle is a wound and ostomyDr Black is an Associate Professor of Dr Clark is a Visiting Professor in of Nursing and Tissue Viability at the consultant for the VirginiaNursing at the University of Nebraska Tissue Viability, Birmingham City Catholic University of Portugal and Commonweath University Medicalin the USA. She is a Fellow of the US University, UK and Manager of the researcher of the Portuguese Wound Center, Richmond, in the USA. HisAcademy of Nursing and currently on Welsh Wound Network. He is also Management Association. Pressure clinical specialty area includesthe Board of the National Pressure President of the European Pressure Ulcers are his main research. He is pressure ulcer prevention in high riskUlcer Advisory Panel. Ulcer Advisory Panel currently a board member of the populations. European Pressure Ulcer Advisory Panel and the European Wound Management Association.Evan Call MS, CSM (NRM) Carol Dealey RN PhD Nick Santamaria RN PhDEvan Call is Adjunct Faculty in the Dr Dealey is Senior Research Fellow Dr Santamaria is Professor ofMicrobiology Department at Weber at University Hospital Birmingham Nursing Research, TranslationalState University, USA, and NHS Foundation Trust and Honorary Research at The University ofundertakes research in relation to Professor in Tissue Viability at Melbourne and The Royal Melbournemedical devices for pressure ulcer University of Birmingham in the UK. Hospital, Australia. His researchprevention. He is currently on the Her main research programme is the involves the prevention of pressureBoard of the National Pressure Ulcer prevention of pressure ulcers. She is ulcers in critically ill trauma patientsAdvisory Panel. a Past President of the European in ICU. Pressure Ulcer Advisory Panel.
What have we been doing?1. A literature review of current evidence which included both clinical and laboratory studies relating to the use of dressings for pressure ulcer prevention2. This improved our understanding of their role in reducing the impact of pressure, shear and microclimate3. This information provided the evidence we needed to develop Best Practice Statements of the likely effectiveness of dressing when used in pressure ulcer prevention alongside other prevention methods. These statements were presented at the WUWHS Conference in Japan in a Quick Reference Guide4. We are planning a full document with all the evidence to be submitted for publication in a wound journal
• So what do dressings do in pressure ulcer prevention?
Shear redistribution The dressing translates shear force to the skin outside the area of concern.Without a dressing Within the dressing the interface of multiple layers aids in the absorption of shear
Friction reduction If the surface of the dressing is slipperyWithout a dressing it will reduce friction, conversely if it is not it will increase friction.
Pressure• redistribution Without a dressing A dressing with adequate thickness distributes forces over a larger area thus accomplishing pressure re-distribution
Balance of Skin MicroclimateWith a basic dressing With a multi layer silicone foam dressing
Balance of MicroclimateA dressing that maintains relative humidity ofbetween 40 and 80% at the skin surface helpsmaximise the resilience of the skin.Dressings that trap moisture at the skin surfacereduce the strength of the skin and lead tomaceration.Dressings that withdraw too much moisture canpredispose skin to stiffness and cracking.This can be identified by obvious signs ofmaceration or dryness.
Do some dressings outperform others?• Laboratory tests found a multilayer silicone dressing out- performed others• But need clinical confirmation – there are some cohort studies + awaiting the results of an Australian RCT
In the meantime….Based on what weknow so far wehave produced adressing selectionguide
Part of the Dressing Selection Guide for Pressure Ulcer Prevention in the Sacrum and ButtocksMechanism of Injury Mechanisms of Dressing SelectionPressure, Friction, ProtectionShear & MicroclimateElevating the head of the The dressings used for Structure:bed increases pressure and pressure ulcer preventionshear on the pelvic region, should: A multi layer silicone foamnote the percent of body 1. Redistribute pressure dressingmass that is focused on the 2. Minimise shear with the ability to redistributepelvic region as the head of 3. Balance micro-climate pressure, redistribute andbed is raised. 4. Reduce friction absorb shear, and0° = 30% of body mass 5. Prevent mechanical effectively manage30° = 44% of body mass stripping of skin when microclimate.45° = 52% of body mass removing the dressing to90° = 70% of body mass inspect the skin 6. Provide barrier protection to the skin 7. Have an atraumatic contact layer
You can get a copyFrom the NeveStand in theExhibition
So what have I learnt from this project?• We had an initial meeting followed by teleconferences. This worked when we were assembling the evidence.• It did not work for writing the Best Practice Statements and we ended up meeting for 2 days to write them• Meetings are essential for writing guidelines or best practice statements
Overall Conclusions• It is good to work with colleagues from other countries – people are the same everywhere, we just need to get better at talking to each other• Nurses can make an important contribution – but we need to work in multi-professional groups in order to produce really significant outcomes