Evidence-Based Practice (EBP) Guidelines for today's nurses and patients regarding diabetics and hosptial care.

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2. Evidence-
Based
Practice

3. 3
EBP
Evidence-Based Practice (EBP): What is it?

4. Terminology/Abbreviations
4
ü Negative Pressure Wound Therapy (NPWT)
ü Saline moistened gauze Therapy (SMGT)
ü Vacuum assisted closure (VAC) Therapy
ü Quality-adjusted life-years (QALYs)
ü Virtual Patients (VP)
ü Advanced wound care (AWC)
ü Curative Health Services (CHS)
ü Diabetic foot ulcers (DNFU)
ü Short-form McGill Pain Questionnaire (SF-
MPQ)

5. Globally,as nurses, it is within our power to create
and implement new and innovative treatments and
types of therapy for our patients.
We must also ascertain the treatment’s
usefulness; at this juncture in time, it is
critical to the overall health and improvement
of our patients.
Patients and their families trust us as nurses.
We are expected to be at the forefront of where
solutions and knowledge meet expectations,
and where they also meet with frustrationand
time constraints.
Despite our best efforts, we frequentlymiss the
most current research and dynamics within
technology. Now is the time that nurses discover
new options.
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Evidenced-basedPractice

6. Evidence-Based
Practice (EBP)
6
We formulated a research question based on the inadequate information available to
nurses regarding the better choice between Saline Moistened Gauze Therapy
(SMGT) versus Negative Pressure Wound Therapy (NPWT) for Diabetic Foot Ulcers
(DFU).
In order to obtain the best peer-reviewed research articles, we had to establish what
the best sources were that were available to us. Once we did this, we had to ascertain
their credibility and relevancy to our predetermined research question.
After assessing and reviewing our articles, we began to synthesize data that we had
obtained from them. Within each source, we made certain that we found the sections
of the article that were similar and that were different. With this information, we were
able to compare the articles for their pertinent relevancy to our research question.
As we obtained the data that we planned to use as a synthesized summary of our
articles, we began to use that data to create and devise a proposal that we could use to
change the manner in which nurses practice in a particular area. This process change
will enable nurses to comprehend the importance of the changes that we will
implement.
Both steps 5 & 6 will be accomplished outside of the classroom or university. At this
juncture, we will plan to implement any changes that we deem necessary, as well as
evaluate the outcome. Once again, we will continually be assessing and analyzing the
progress, or lack thereof, of any changes that we have implemented.
Step 1
Step 2
Steps 5 &
6
Step 3
Step 4

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•Population: Diabetic type 2 patients with diabetic
foot ulcers (DFU).
Population: A specific population and setting
•Intervention: Conventional Saline Moistened Gauze
Dressing (SMGD) Therapy
Intervention/Interest: A condition of interest
•Negative Pressure Wound Therapy (NPWT)
Comparison: Exposure to new treatment or therapy
•An increase in healing diabetic type II DFUs
Outcome: at least one specific outcomes
P I C O

8. Phase 2:
Validation
a. Synthesis
summary
b. Grade and
evaluate
strength of
evidence
from articles
Phase 3:
Comparativ
e evaluation
a. Research
fit question?
b. Feasibility
c. Potential
obstacles
d. Current
practice
Phase 4:
Decision
Stage
a. Who makes
the decisions?
b.Implications
for patient
c. Impact on
practice
currently
Phase 5:
Translation
Application
a. Findings
be used?
b. Protocol
implement
findings
c. Are there
implications
for practice?
Phase 6:
Evaluation
a. Clarify
anticipated
outcomes
b. How exactly
will protocol be
evaluated
c. Will data be
used to
evaluate care8
Stetler Model

9. PICO Question
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Can diabetic type 2 patients with diabetic
ulcers be treated more effectively with
conventional Saline Moistened Gauze
Dressings (SMGD) Therapy or Negative
Pressure Wound Therapy (NPWT)?

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Synthesis Summary
Vacuum Assisted Closure (VAC) Therapy or Negative Pressure Wound Therapy (NPWT) has
proven to be significantly more effective then Saline Moistened Gauze Therapy (SMGT) for
Advance Wound Care (AWC). VAC Therapy or NPWT has yielded many improvements when
compared to Saline Moistened Gauze Therapy (SMGT), including the following:
Ø Fewer amputations with less infections
Ø Increased amount of ulcers healed in less time
Ø Additional Quality Adjusted Life-Years (QALYs)
Ø Lower cost, specifically due to decreased need of nurses
Ø Decreased need of nursing staff and time
Treatment of diabetic foot ulcers (DFU) can place a great deal of emphasis and economic pressures
on healthcare resources due to prolonged hospitalization, rehabilitation, skilled facility care, and
nursing care. Suggestive counseling for patients is a prominent idea and improves overall QALYs.
The rate and evaluation of the strength of evidence found in the six articles were quiet diverse,
ranging from a grade 1 for poor to 4 for excellent. The average score was 2.5.

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Comparative Evaluation
Ø One-third of our articles will provide research that will correlate with our developed question. All
of our articles referred to review boards, clinical experts, and other types of resources to help
guarantee their authenticity, with only one exception.
Ø Two-thirds mentioned time restrictions might have altered their results, insinuating that they
would have been better if their studies had proceeded longer. Each of these articles stated if they
had more time their results would have demonstrated a greater statistical significance on behalf of
NPWT. The same four articles mentioned their concern about randomness and its effect on
methodological limitations while another article questioned a possible database intervention
corrupting the randomness of their test.
Ø The consensus was that VAC would vastly improve patient’s QALYs, as noted in the previous
slide. There is significant evidence that NPWT improves granulation tissue formation, decreases
time to heal, and reduces the overall cost of treatment compared with SMGT. Standards, texts,
and health care professionals have begun to switch to VAC/NPWT as their standard of care for
DFUs.

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Decision Stage
Those primarily mentioned in the article that would be specifically involved in the decision-
making were the physicians, researchers, institutions, third parties, and government.
Implications mentioned for the patient in regards to a change in practice would include a
decrease in cost, increased flexibility and efficacy for patients, increased healing time and
decreased amputations. It is vital that patients educate themselves on the type and procedure of
the therapy they select. The patient’s preference is what is best for him or her. Our articles refer
to the patient’s preference as being affordable, safe, effective, and ultraportable.
There is a significant impact on practices of our five out of six articles. This impact is because
using the VAC increases the healing time and the probability of amputations. In addition, it ends
up being less costly in the long run because you don’t have to pay nurses for home healthcare or
hospital stay to continually come in and change the saline gauze dressings twice today. The
article states that VAC Therapy was the dominant and preferred method of treatment for
patients, which increased the number of patients for the practice/manufacturers that were
mentioned in the articles.

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Translation/Application
Physicians, healthcare providers, third parties, pharmaceuticals, the government, OT and PT,
to name just a few, can use the findings from these articles. All would benefit due to the
insight gained with which patients would be more likely to respond instead of standard care
therapy. As previously mentioned, diabetic patients are more than likely to see drastic
improvements their QALY. Two thirds of the articles state that there is a significant
difference between SMGT and NPWT – with NPWT significantly better.
These articles promote the need for additional research in order to establish standardized
guidelines for nurse-administered diabetic foot care programs, such as published algorithms.
Furthermore, peer-reviewed articles help to encourage nurses into taking action and
establishing their own programs to help their diabetic patients. These programs would use
VAC Therapy to replace the saline gauze treatments on a standard basis, unless
contraindicated. Healthcare workers need to be better educated about the causation and
cessation of pain options for patients. furthermore, healthcare workers must become better
educated about their patients as individuals; assessing and learning what they can do to
improve their patients QALY.

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Evaluation
When evaluating the articles, it was necessary to clarify the anticipated outcomes that each
declared. Although the articles all pertain to diabetes, their outcomes are quite diverse. They
include the following:
DFU pain is not limited to patients experiencing infection or other complications. Pain
must be assessed on an individual basis.
Patients would have an improved QUAL if they received a proper diagnosis,
treatment, and prognosis due to a more thorough and comprehensive exam of DFU.
Nurses should strongly consider becoming involved in developing preventative foot
care nursing programs for diabetic patients.
Importance of evaluating prognostic information, in correlation with the patient’s
treatment plan, should be done with a real-time administrative database.
Protocol was be evaluated using review boards, statistically through patient treatment and
outcomes, the short form McGill pain questionnaire (SF-MPQ), and by researchers using a
randomized study group and control group. Multiple reliable statistical analyzes were performed
using several methods; multiple reliable statistical analyzes were performed using several
methods.

15. Wet-to-dry dressings are
cost prohibitive secondary
to caregiver time and
frequency of change, as
licensed nurses’ salaries
and benefits tend to be one
of the highest expenses for
a facility.
Saline-moistened gauze
has been the standard
method; however, it has
been difficult to
continuously maintain a
moist wound environment
with these dressings.
Wet-to-dry is a painful and
traumatic dressing that
can cause substantial
patient discomfort and
wound bed disturbance as
well as poor patient
compliance or adherence.
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Saline Moistened Gauze Dressing (SMGD) Therapy

16. V.A.C. Therapy
results in more
Quality
Adjusted Life-
Years (QALYs),
at a lower cost
V.A.C. Therapy
results in more
ulcers healed, at
a lower cost
V.A.C. Therapy
results in fewer
amputations, at
a lower cost
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V.A.C. appears to
be more effective,
safe, and patient
satisfactory for the
treatment of
DFUs.

17. Negative Pressure Wound Therapy (NPWT)
or Vacuum-assisted Closure (VAC) Therapy
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18. Evidence-based
Practice1
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Never cease to assess the need to make any changes or
to stop evaluating what you find.Amber Huett and David MacMillan June 2011
UNA Center for Writing Excellence 1
5. Implement and evaluate: Apply the necessary changes and assess the changes to acquire new
evidence.
6. Integrate and maintain changes: Reassess based on new evidence to continue improvement.
The first four steps can be completed in a college classroom setting and are often given as a research
paper assignment. Steps five and six require the use of a healthcare environment. Remember, these
steps are all interlocking. Never stop assessing the need for change or evaluating what you find. The
following diagram, adapted from Larrabee (2009), illustrates this:
Step 1
Collect internal data on current
practice
Link problems, interventions, and
outcomes
Step 2
Identify sources of evidence
Refine research strategy
Conduct the research
Step 3
Appraise the value of the
evidence
Synthesize the best evidence
Assess the risks and benefits of
the new practice
Step 4
Define proposed changes
Identify the necessary resources
Design the implementation
Step 5
Implement the proposed
changes
Evaluate process and outcome
Generate conclusions
Step 6
Recommend broader changes
Integrate changes into standards
of practice
Monitor process and outcome
periodically

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References
Armstrong, D. G., Marston, W. A., Reyzelman, A. M., & Kirsner, R. S. (2012).
Comparative effectiveness of mechanically and electrically powered negative pressure
wound therapy devices: A multicenter randomized controlled trial. Wound Repair and
Regeneration, 20, 331-342. doi:10.1111/j.1524-475X. 2012.00780.x
Bradbury, S. E. (2011). Diabetic foot ulcer pain: The hidden burden (Part one).
European Wound Management Association Journal, 11(1), 11-22.
Fujiwara, Y., Kishida, K., Terao, M., Takahara, M., Matsuhisa, M., Funahashi, T.,
Shimomura, I., & Shimizu, Y. (2011). Beneficial effects of foot care nursing for
people with diabetes mellitus: an uncontrolled before and after intervention study.
Journal of Advanced Nursing, 67(9), 1962-1972. doi10.1111/ j.1365-
2648.2011.05640.x
Huett, A., & MacMillan, H. (2011). Evidence-based practice. UNA Center for Writing Excellence,
Retrieved from https://www.una.edu/writingcenter/docs/Writing-Resources/Evidence-
Based Practice.pdf

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Kurd, S. K., Hoffstad, O. J., Bilker, W. B., & Margolis, D. J. (2009). Evaluation of the use of
prognostic information for the care of individuals with venous leg ulcers or diabetic
neuropathic foot ulcers. Wound Repair and Regeneration, 17, 318-325. doi:10.1111/j.
1524-475X.2009.00487.x
Nain, P. S., Uppal, S. K., Garg, R., Bajaj, K., & Garg, S. (2011). Role of negative
pressure wound therapy in healing of diabetic foot ulcers. Journal of
Surgical Technique & Case Report, 3(1), 17-22. doi10.4103/2006-8808.78466
1National collaborating center for methods and tools. (2011). Stetler model of evidence-based
practice. Hamilton, ON: McMaster University. Retrieved from
http://www.nccmt.ca/registry/view/eng/83.html
Whitehead, S. J., Forest-Bendien, V. L., Richard, J. L., Halimi, S., Van, G. H., &
Trueman, P. (2010). Economic evaluation of vacuum assisted closure therapy for the
treatment of diabetic foot ulcers in France. International Wound Journal, 8(1),
22-30.
References

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