EVIDENCE-BASED WOUND CARE

EVIDENCE-BASED WOUND CARE

Laura Bolton, Ph.D., Adjunct Associate Professor, Dept. of Surgery, Bioengineering Section

University of Medicine & Dentistry of New JerseyPresident, BoltonSCI, LLC

E-mail: llbolton@gmail.com

Laura Bolton, Ph.D., Adjunct Associate Professor, Dept. of Surgery, Bioengineering Section

University of Medicine & Dentistry of New JerseyPresident, BoltonSCI, LLC

E-mail: llbolton@gmail.com

GOALSGOALS

1. Define evidence-based (EB) wound care

2. Describe EB wound care principles and how to integrate them into your wound care practice.

3. Review results reported using EB protocols of wound care

1. Define evidence-based (EB) wound care

2. Describe EB wound care principles and how to integrate them into your wound care practice.

3. Review results reported using EB protocols of wound care

“EVIDENCE-BASED MEDICINE IS…“EVIDENCE-BASED MEDICINE IS…

The conscientious, explicit, and judicious use of current best evidence in making

decisions about the care of individual patients.” 1

The conscientious, explicit, and judicious use of current best evidence in making

decisions about the care of individual patients.” 1

1Sackett DL et al. Br Med J, 1997; 312:71-77.

Sir Isaac Newton1642-1727

Sir Isaac Newton1642-1727

If I have seen further,

It is by standing upon

The shoulders of giants.

If I have seen further,

It is by standing upon

The shoulders of giants.

DIAGNOSE,CARE FORWOUND, PATIENT

DIAGNOSE,CARE FORWOUND, PATIENT

PROVIDE CAREPROVIDE CARE MORE CARE...MORE CARE...

YOU CAN CHOOSE…

CARE FOR WOUNDS

YOU CAN CHOOSE…

CARE FOR WOUNDS

OR

HEAL WOUNDS

using evidence-based practice.

OR

HEAL WOUNDS

using evidence-based practice.

Scope Of Evidence-Based Wound CareScope Of Evidence-Based Wound Care

• WHO can use EB wound care? – All disciplines: MD, RN, ET, APN, PT, DPM ...

• WHERE– All settings: Home, Hospital, Skilled Care...– All indications: Post-op, traumatic, chronic ...

• HOW– Diagnosis, predicting outcomes and therapy

• WHAT IS USED– Evidence of both benefits and risks– To derive patient-centered wound outcomes

• WHO can use EB wound care? – All disciplines: MD, RN, ET, APN, PT, DPM ...

• WHERE– All settings: Home, Hospital, Skilled Care...– All indications: Post-op, traumatic, chronic ...

• HOW– Diagnosis, predicting outcomes and therapy

• WHAT IS USED– Evidence of both benefits and risks– To derive patient-centered wound outcomes

How Does EB Wound Care Differ From Traditional Wound Practice?1

How Does EB Wound Care Differ From Traditional Wound Practice?1

Traditional

• Focus on practice• Parental approach• Clinician oriented • Expert opinion-based

Traditional

• Focus on practice• Parental approach• Clinician oriented • Expert opinion-based

Evidence-Based

• Focus on outcomes• Informed decision• Patient oriented• Science-based

Evidence-Based

• Focus on outcomes• Informed decision• Patient oriented• Science-based

1 1 Jaeschke R, Guyatt GH, Meade M. Jaeschke R, Guyatt GH, Meade M. Adv Wound CareAdv Wound Care 1999; 11(5):214 1999; 11(5):214

Doctor's Visit Traditional Evidence-Based

Doctor's Visit Traditional Evidence-Based

"I think you should take this therapy."

"Be sure you follow the instructions."

"I think you should take this therapy."

"Be sure you follow the instructions."

Based on the evidence,

•Therapies A or B may help you achieve your wound care goals.

•The risks, benefits and costs of each therapy are...

•Which would you be most comfortable using?

HALLMARKS OF GOOD EVIDENCE1,2HALLMARKS OF GOOD EVIDENCE1,2

• Randomized assignment of patients• Independent blinded comparison of treatment effects

or comparison to accepted standard• Efficacy and safety measured and reported• Valid outcomes measured reliably• Clinically relevant, patient-centered outcomes• Representative, similar patient samples• Adequate timing and scope of follow up

1Jaeschke R et al. Adv Wound Care, 1998; 11(5):214-2182 Gray M. et al. JWOCN 2004; 31(2):53-61.

• Randomized assignment of patients• Independent blinded comparison of treatment effects

or comparison to accepted standard• Efficacy and safety measured and reported• Valid outcomes measured reliably• Clinically relevant, patient-centered outcomes• Representative, similar patient samples• Adequate timing and scope of follow up

1Jaeschke R et al. Adv Wound Care, 1998; 11(5):214-2182 Gray M. et al. JWOCN 2004; 31(2):53-61.

Benefits Of EB Wound CareBenefits Of EB Wound Care

• Reliable, safe patient outcomes

• Consistently managed patients

• Reduced recurrence

• Improved professional reputation

• Reduce legal liability

• Economically sound outcomes

• Reliable, safe patient outcomes

• Consistently managed patients

• Reduced recurrence

• Improved professional reputation

• Reduce legal liability

• Economically sound outcomes

Some EBM Resources: http://www….Some EBM Resources: http://www….

• Cochrane Initiative– cochrane.org/

• McMasters– shef.ac.uk/uni/academic/R-Z/scharr/

triage/index/EBM.htm

• National Library of Med. (MEDLINE)– ncbi.nlm.nih.gov/PubMed/

• National Guideline Clearinghouse

– guideline.gov/

• Cochrane Initiative– cochrane.org/

• McMasters– shef.ac.uk/uni/academic/R-Z/scharr/

triage/index/EBM.htm

• National Library of Med. (MEDLINE)– ncbi.nlm.nih.gov/PubMed/

• National Guideline Clearinghouse

– guideline.gov/

BRIDGING THE GAP BETWEEN EVIDENCE AND PRACTICE

INTEGRATING EVIDENCE-BASED PRINCIPLES INTO WOUND PRACTICE

BRIDGING THE GAP BETWEEN EVIDENCE AND PRACTICE

INTEGRATING EVIDENCE-BASED PRINCIPLES INTO WOUND PRACTICE

Implementing EB Principles In Wound Care Practice

Implementing EB Principles In Wound Care Practice

G: Identify patient-oriented GOAL

A: Evidence-based ACTION PLAN

P: Measure PROGRESS

Hermans MHE, Bolton LL, Establishing a skin integrity program. Remington Report, 2001; 9(6) Suppl. 1:6-8

Patient-oriented Goal Guides the Action PlanPatient-oriented Goal Guides the Action Plan

If the GOAL is...

• Reduce edema• Reduce pressure• Protect wound• Protect skin• Minimize pain, odor• Manage excess fluid• Reduce infection risk• Heal the wound• Minimize scar

If the GOAL is...

• Reduce edema• Reduce pressure• Protect wound• Protect skin• Minimize pain, odor• Manage excess fluid• Reduce infection risk• Heal the wound• Minimize scar

ACTION plan requires...

• High multi-layer compression• Pressure relief surface or shoe• Off-load insensate extremity• Moisturizing skin barrier• Moisture barrier wound dressing• With optional absorbent primary

dressing• Moisture barrier wound dressing

ACTION plan requires...

• High multi-layer compression• Pressure relief surface or shoe• Off-load insensate extremity• Moisturizing skin barrier• Moisture barrier wound dressing• With optional absorbent primary

dressing• Moisture barrier wound dressing

Evidence-based (EB)

Action To Manage Patient and Wound

Evidence-based (EB)

Action To Manage Patient and Wound

• Diagnose & correct tissue damage causes

• Optimize wound bed & surrounding skin

• Provide moist healing environment

Diagnose….Diagnose….

Diagnose and correct the cause(s) of tissue damage!

Diagnose and correct the cause(s) of tissue damage!

Chronic wounds require a multidisciplinary team to diagnose and

correct the cause.

Chronic wounds require a multidisciplinary team to diagnose and

correct the cause.

• Contributing factors– Vasculature– Nutrition– Endocrinology– Immune Disorders– Infection– Excessive/Prolonged

Pressure/Moisture– Repeated Physical or

Chemical Trauma

• Contributing factors– Vasculature– Nutrition– Endocrinology– Immune Disorders– Infection– Excessive/Prolonged

Pressure/Moisture– Repeated Physical or

Chemical Trauma

The wound is attached to A PATIENT.

Local care can’t do this alone!

Example EB Principles to Use on Full- and Partial-thickness Acute Wounds

Example EB Principles to Use on Full- and Partial-thickness Acute Wounds

• If wound is bleeding achieve hemostasis rapidly1

• Cool burned tissue, but avoid hypothermia2

• Minimize time between trauma and surgery1

• Debride necrotic tissue or debris2,3

– Avoid use of wet-to-dry gauze in debriding3

• Select dressing(s) to meet functional wound needs4,5

– Maintain hemostasis or moist environment, absorb exudate, debride autolyticallly, isolate/protect wound, minimize pain, odor or bioburden

• Evaluate and minimize patient-reported pain2,3

• If wound is bleeding achieve hemostasis rapidly1

• Cool burned tissue, but avoid hypothermia2

• Minimize time between trauma and surgery1

• Debride necrotic tissue or debris2,3

– Avoid use of wet-to-dry gauze in debriding3

• Select dressing(s) to meet functional wound needs4,5

– Maintain hemostasis or moist environment, absorb exudate, debride autolyticallly, isolate/protect wound, minimize pain, odor or bioburden

• Evaluate and minimize patient-reported pain2,3

1Spahn DR et al. Critical Care 2007; 11(1): 1-22 (EU Guideline)2www.health.nsw.gov.au/gmct/burninjury/docs/guidelines_burn_wound_management.pdf (AU Guideline, accessed 2 June 2007)3Nat. Inst. for Clin. Excellence. Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. Tech. Appraisal Guid. #24, April 2001.4Harding K et al. Diab Metab Res Rev 2000; 16(Suppl. 1):S47-S50. 5van Rijswijk L, Beitz J. J. W. O. C. N. 1998; 25(3):116-122.

EB Practice for Wound Dressings:MEDLINE Search 4-Jun-2007 Found (N) Controlled Studies Supporting

Faster Healing and Reduced Pain, Scarring or Infection Rates using Film or Hydrocolloid than with Non-Barrier Dressings (e.g.Gauze)

EB Practice for Wound Dressings:MEDLINE Search 4-Jun-2007 Found (N) Controlled Studies Supporting

Faster Healing and Reduced Pain, Scarring or Infection Rates using Film or Hydrocolloid than with Non-Barrier Dressings (e.g.Gauze)

• Abrasions (4)• Amputation sites (1)• Biopsy sites (6)• Blisters (1)• Burns (6)• Circumcisions (1)• Epidermolysis bullosa(1)• Excoriations, trauma (1)• Flap survival(1)

• Abrasions (4)• Amputation sites (1)• Biopsy sites (6)• Blisters (1)• Burns (6)• Circumcisions (1)• Epidermolysis bullosa(1)• Excoriations, trauma (1)• Flap survival(1)

• Ischemic wounds (1)• Hypospadias (1)• Laser resurfacing (2)• Mohs excisions (1) • Pressure ulcers (2)• Skin tears (1)• Skin graft donor sites (6)• Surgical incisions (1)• Vein harvest incision site (1) • Venous ulcers (2)

• Ischemic wounds (1)• Hypospadias (1)• Laser resurfacing (2)• Mohs excisions (1) • Pressure ulcers (2)• Skin tears (1)• Skin graft donor sites (6)• Surgical incisions (1)• Vein harvest incision site (1) • Venous ulcers (2)

Example steps in ImplementingEB Pressure Ulcer Management1-4

Example steps in ImplementingEB Pressure Ulcer Management1-4

• Correct causes of tissue damage – prolonged pressure, friction, sheer1-4

– nutritional deficiencies1-4

• Wound bed – Debride necrotic tissue4

– Treat local or distant infection2

• Protect skin from– excess moisture or dryness1,3,4

– chemical or physical trauma1,3,4

• Maintain a moist wound environment1-4

Pressure ulcer treatment & prevention guidelines: AHRQ,1 WHS2 and WOCN3

4Kerstein et al. Disease Management Health Outcomes, 2001; 9(11):651-663

EB Venous Ulcer Management1,2,3EB Venous Ulcer Management1,2,3

• Diagnose and correct the cause– Rule out arterial cause:

• Ankle/brachial index (ABI) > 0.9• ABI 0.7-0.9 compress with care

– Sustained, graduated, high, 2- to 4- layer elastic compression

– Elevate limb, flex ankle or walk– Elastic stockings prevent recurrence

• Manage exudate and dermatitis• Moist wound environment

• Diagnose and correct the cause– Rule out arterial cause:

• Ankle/brachial index (ABI) > 0.9• ABI 0.7-0.9 compress with care

– Sustained, graduated, high, 2- to 4- layer elastic compression

– Elevate limb, flex ankle or walk– Elastic stockings prevent recurrence

• Manage exudate and dermatitis• Moist wound environment

11McGuckin M, et al. McGuckin M, et al. Amer J SurgeryAmer J Surgery 2002; 183:132-137. 2002; 183:132-137.

22Bolton et al. Bolton et al. Ostomy/Wound Mgmt , , 2006; 52(11):32-48 (AAWC Guideline)33Kerstein MD Kerstein MD et al. Dis. Manage. Health Outcomeset al. Dis. Manage. Health Outcomes, 2001;9(11),651-63, 2001;9(11),651-63

Venous ulcers heal as edema declineswith sustained, graduated, high compression.

Duby et al. Wounds 1993; 5(6): 276-279.

Venous ulcers heal as edema declineswith sustained, graduated, high compression.

Duby et al. Wounds 1993; 5(6): 276-279.

Sustained high, graduated compression

Compression?

EB Action Plan To Manage Arterial or Ischemic Ulcers

• Diagnose, correct related conditions1,2

– Peri-wound TcPO2 < 20 mmHg predicts non-healing1

– Vascular specialist locate, correct arterial blockage

• Prompt referral if rest pain and/or gangrene2

• Remove necrotic tissue– limit microorganisms2

• Avoid nicotine1,2

• Diagnose, correct related conditions1,2

– Peri-wound TcPO2 < 20 mmHg predicts non-healing1

– Vascular specialist locate, correct arterial blockage

• Prompt referral if rest pain and/or gangrene2

• Remove necrotic tissue– limit microorganisms2

• Avoid nicotine1,2

1Hopf H. et al. Wound Rep Regen, 2006; 14: 693-710. (WHS Guideline)2Kerstein MD. Kerstein MD. Ostomy/Wound MgmtOstomy/Wound Mgmt 1996; 42(10A Suppl):19S-35S 1996; 42(10A Suppl):19S-35S

EB Diabetic Foot Ulcer Management1,2,3EB Diabetic Foot Ulcer Management1,2,3

• Diagnose and correct the cause– Control diabetes (HbA1c < 6.5%)– ABI > 0.9 rules out arterial insufficiency– ABI > 1.3 rigid vessel wall; use great toe– No ABI, use TcPO2 > 40 mmHg

• Check for neuropathy– Semmes-Weinstein 10 g (#5.07) fiber– Protect skin and off load

• Wound/Skin:– Gel debridement speeds DFU healing4 – No healing progress: suspect infection

• Moist wound environment3

• Diagnose and correct the cause– Control diabetes (HbA1c < 6.5%)– ABI > 0.9 rules out arterial insufficiency– ABI > 1.3 rigid vessel wall; use great toe– No ABI, use TcPO2 > 40 mmHg

• Check for neuropathy– Semmes-Weinstein 10 g (#5.07) fiber– Protect skin and off load

• Wound/Skin:– Gel debridement speeds DFU healing4 – No healing progress: suspect infection

• Moist wound environment3

1Steed et al. Wound Rep Reg (2006) 14 680–692 (WHS Guideline)2Crawford et al. WOCN Guideline 3 …Lower extremity neuropathic disease3Amer Diab Assn Consensus Dev. Conf., Diabetes Care 1999; 22(8):1354-1360.42Smith J, Thow J. The Diabetic Foot 2003; 6(1):12-16

Consistent, Continuous Off-loading

Consistent, Continuous Off-loading

One barefoot walk to the bathroom can One barefoot walk to the bathroom can undo a week of healing.undo a week of healing.

Evidence For Minimizing Wound InfectionsEvidence For Minimizing Wound Infections

Infection is 5x more likely in DFU than in non-diabetic chronic wounds4

• Passive Mechanisms– Isolate and protect wound 1,2

– Debride necrosis, foreign matter3 • Active Mechanisms3

– Topical antimicrobial agents– If signs of infection are present,

• Biopsy or quantitative swab to identify infecting organism

• Prescribe correct systemic antibiotic

• Passive Mechanisms– Isolate and protect wound 1,2

– Debride necrosis, foreign matter3 • Active Mechanisms3

– Topical antimicrobial agents– If signs of infection are present,

• Biopsy or quantitative swab to identify infecting organism

• Prescribe correct systemic antibiotic

1Hutchinson JJ, McGuckin M. Amer J Infec Control 1990; 18(4):257-268.2 Wilson P, et al. The Pharmaceutical Journal December 17, 1988; 787-788. 3 Steed et al. Wound RepRegen, (2006) 14 680–692 4 Rubinstein, Am. J. Med. 1983; 75(1):161

Moist Environment to Protect, Isolate Wound: Fewer Infections in Diabetic Neuropathic UlcersMoist Environment to Protect, Isolate Wound:

Fewer Infections in Diabetic Neuropathic Ulcers

BOULTON et al. Wound Rep Reg 1999;7:7-16

Retrospective study• Clinical infections

– diabetic foot ulcers

• Off-load + Dressings:– Hydrocolloid (HCD)– Traditional Gauze

BOULTON et al. Wound Rep Reg 1999;7:7-16

Retrospective study• Clinical infections

– diabetic foot ulcers

• Off-load + Dressings:– Hydrocolloid (HCD)– Traditional Gauze

Percent Clinical Infections Reported

6

2.5

0

1

2

3

4

5

6

Gauze HCD

Protocols of CareProtocols of Care

Moist Environment to Protect, Isolate Wound Reduces Risk of Infection: All Wounds

Moist Environment to Protect, Isolate Wound Reduces Risk of Infection: All Wounds

Hutchinson & McGuckinAmer J Infect Control, 1990; 18:257

• Retrospective 30 yr literature review

• Clinical infections• 1085 gauze (all types)• 1351 hydrocolloid (HCD)• 617 foam dressings• 1021 film dressings

Hutchinson & McGuckinAmer J Infect Control, 1990; 18:257

• Retrospective 30 yr literature review

• Clinical infections• 1085 gauze (all types)• 1351 hydrocolloid (HCD)• 617 foam dressings• 1021 film dressings

Percent Clinical Infections Reported

HCD

7.1

1.32.4

4.5

0

2

4

6

8

Gauze Foams Films

ProtocolProtocol

EB Practice: Debride Necrotic Tissue1EB Practice: Debride Necrotic Tissue1

• Healing efficacy2 only for autolytic gel debridement– Compared to saline gauze on

diabetic foot ulcers

• Debriding efficacy– Autolytic as fast as enzyme on

venous3 or pressure4 ulcers

• Be aware – Wounds will appear larger after

necrotic tissue is removed

1AHCPR Guidelines for Tx, Px of Pressure Ulcers2Smith & Thow The Diabetic Foot, 2003; 6(1):12-16.3 3 Romanelli, Wounds, 1997;9:122-126.4Burgos A et al. Clin Drug Invest. 19(5):357-365)

Debridement Types• Surgical/ Sharp• Enzymatic• Autolytic• Mechanical

Debridement Types• Surgical/ Sharp• Enzymatic• Autolytic• Mechanical

Implementing EB Wound Care: Measure

Progress Toward Goal

Implementing EB Wound Care: Measure

Progress Toward GoalWhy measure?

• Support care decisions• Encourage patient• Early warning of:

– infection – non-healing (4 wk <20%

decrease in wound area)

• Benchmark outcomes• Identify problems

Why measure?

• Support care decisions• Encourage patient• Early warning of:

– infection – non-healing (4 wk <20%

decrease in wound area)

• Benchmark outcomes• Identify problems

What to Measure

• Wound dimensions• Wound bed

– Necrotic tissue– Granulation– Epithelization

• Exudate• Odor• Pain

What to Measure

• Wound dimensions• Wound bed

– Necrotic tissue– Granulation– Epithelization

• Exudate• Odor• Pain

PRESSURE ULCER HEALING(Full-Thickness, Mean Initial Area 6.3 cm2)

PRESSURE ULCER HEALING(Full-Thickness, Mean Initial Area 6.3 cm2)

Slow Wound Contraction Warns of Non-Healing

-150

-100

-50

0

50

100

150

2 4 6 8 10 >12

Weeks of Care

% C

ontr

actio

n

HEALING (N=17) NON-HEALING (N=25)

Slow Wound Contraction Warns of Non-Healing

-150

-100

-50

0

50

100

150

2 4 6 8 10 >12

Weeks of Care

% C

ontr

actio

n

HEALING (N=17) NON-HEALING (N=25)

****

** ** **

vanRijswijk L. vanRijswijk L. DecutitusDecutitus, , 1993;6(1):16‑21. * * <0.01 <0.01

EB Practice: Pressure Ulcer HealingMeta-analysis

EB Practice: Pressure Ulcer HealingMeta-analysis

Proportion of ulcers healed at 12 weeks

51%

61%

48%

0%

10%

20%

30%

40%

50%

60%

70%

Gauze HCD D HCD C

Local Wound Dressing in Protocol of Care

Kerstein MD, Kerstein MD, et al. Disease Management and Health Outcomeset al. Disease Management and Health Outcomes, 2001;9(11),651-663, 2001;9(11),651-663

N=102 N=281 N= 136N=102 N=281 N= 136

EB Practice: Venous Ulcer HealingMeta-analysis

EB Practice: Venous Ulcer HealingMeta-analysis

Proportion of ulcers healed at 12 weeks

39%

51%45%

0%

10%

20%

31%

41%

51%

61%

Gauze HCD D Skin Construct

Local Wound Dressing in Protocol with Compression

Kerstein MD, Kerstein MD, et al. Disease Management and Health Outcomeset al. Disease Management and Health Outcomes, 2001;9(11),651-663, 2001;9(11),651-663

N=223 N=530 N=130N=223 N=530 N=130

Diabetic Neuropathic Foot UlcersPerspective: 78% Heal in 10 Weeks With TCC/Hydrocolloid Dressing

Diabetic Neuropathic Foot UlcersPerspective: 78% Heal in 10 Weeks With TCC/Hydrocolloid Dressing

Wagner Grade 2-3 Diabetic Foot Ulcer Healing

0

10

20

30

40

50

60

70

AQ(1) APLG(2) REGR (3) DRMG(4) PR(5)

Protocols of Care Including

% H

eale

d D

uri

ng

10-

20 w

eeks

(1) AQUACEL® Hydrofiber® Piagessi A. et al. Diab Med, 1999:S94 : 20 weeks (2) APLIGRAF® Falanga V. Wounds, 2000;12(5) :42A. 12 weeks(3) REGRANEX® Smiell J. et al. Wound Rep Regen 1999; 7:335: 20 weeks (4) DERMAGRAFT® Pollack R. Wounds 1997;9(1):175. 12weeks(5) PROCUREN® Bentkover JD, Champion AH. Wounds, 1993; 5(4):207-215: 20 weeks

Hyd

rofi

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®

Gau

ze

Bio

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red

Sk

in

Gau

ze

Rh

PD

GF

BB

Bio

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Der

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Pla

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elea

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Pla

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Gau

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Gau

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Implementing Evidence-Based

Wound Practice

Implementing Evidence-Based

Wound Practice

How to Implement EB Wound Practice1How to Implement EB Wound Practice1

1. Multidisciplinary wound care team2

2. Identify practices and outcomes to improve3. Facility--make a plan based on:

– Current and future patients and wounds– Current and projected costs and revenues– Forces to use or overcome

4. Select best EB protocols for your practice5. Motivate patients, staff and management with feedback6. Train all involved on protocol use 7. Measure and communicate utilization and outcomes

1. Multidisciplinary wound care team2

2. Identify practices and outcomes to improve3. Facility--make a plan based on:

– Current and future patients and wounds– Current and projected costs and revenues– Forces to use or overcome

4. Select best EB protocols for your practice5. Motivate patients, staff and management with feedback6. Train all involved on protocol use 7. Measure and communicate utilization and outcomes

1 Morrell C. et al. Nurs Stand. 2001 Apr 11-17;15(30):68-73.2 van Rijswijk L. Amer J. Nursing 2004; 104(2):28-30.

Implementing EB Protocols Venous Ulcer Care If expected outcomes not achieved, e.g. little progress in 2-4

weeks, re-evaluate etiology, care

Implementing EB Protocols Venous Ulcer Care If expected outcomes not achieved, e.g. little progress in 2-4

weeks, re-evaluate etiology, care

Beitz JM, Bates-Jensen B. O/WM, 2001; 47(4):33-40Beitz JM, Bates-Jensen B. O/WM, 2001; 47(4):33-40

Example EB VU Protocol

Patient Wound

Goals Based on evaluation

Rule out arterial (ABI)

Reduce edema

Reduce pain

Manage exudate

Heal venous ulcer

Action plan Evidence-Based

Elastic compression agreeable to patient

Absorbent primary dressing, moisture barrier secondary

Progress Measures

Patient-reported pain

Ankle circumference

Length, width, depth

Healing time

Implementing Evidence-Based GuidelinesAvoid Pitfalls

Implementing Evidence-Based GuidelinesAvoid Pitfalls

• Credit protocol only if it was clear cause

• Use objective benchmarks

• Listen to what missing data tells you.

• Listen to and use feedback from– Patients– Staff– Management

• Credit protocol only if it was clear cause

• Use objective benchmarks

• Listen to what missing data tells you.

• Listen to and use feedback from– Patients– Staff– Management

Clinical Outcomes Using Evidence-Based

Protocols of Wound Care

Clinical Outcomes Using Evidence-Based

Protocols of Wound Care

Japan Pressure Ulcer Outcomes Using EB ProtocolOhura T, Sanada H, Mino Y.Wounds 2004; 16(5):157-73

MC/A

TC/A

TC/NA

10

15

20

25

30

35

At time ofenrollment

At the end of study

26.9

31.5

15.8

21.9

MC/A (n=29): modern dressings with a standardized wound management algorithmTC/A (n=34): traditional dressings with a standardized wound management algorithmTC/NA (n=20): traditional dressings without using a standardized wound management algorithm

29.8

22.5

Mea

n P

SS

T S

core

s

MCA improved PUoutcomes at less than half

the total (labor +

materials) cost of TC/NA

Validation Results (N=40 / Group) (P<0.05)

23%

70%

40%

65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pre-Guideline With Guideline Pre-Guideline With Guideline

United States United Kingdom

Per

cen

t H

eale

d i

n 1

2 W

eeks

Validation Results (N=40 / Group) (P<0.05)

23%

70%

40%

65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pre-Guideline With Guideline Pre-Guideline With Guideline

United States United Kingdom

Per

cen

t H

eale

d i

n 1

2 W

eeks

Validating EB Venous Ulcer Guidelines in US and UK(McGuckin M. et al. Amer J Surgery 2002; 183:132-137.)

Validating EB Venous Ulcer Guidelines in US and UK(McGuckin M. et al. Amer J Surgery 2002; 183:132-137.)

Phone/DSL LineNetwork

Speakervideophone

TelemedicineBase Station with

validated Solutions® algorithms

Patient’s Home

Software EB Guidelines in Home TelemedicineSoftware EB Guidelines in Home TelemedicineKobza L, Scheurich A. O/WM . 2000; 46(10):48-53

More Wounds Healed Faster Using EB Practice in Home Telemedicine

(Kobza L, Scheurich A. Ostomy/Wound Manag. 2000; 46(10):48-53)

More Wounds Healed Faster Using EB Practice in Home Telemedicine

(Kobza L, Scheurich A. Ostomy/Wound Manag. 2000; 46(10):48-53)

0.0

5.0

10.0

15.0

20.0

25.0

WE

EK

S T

O H

EA

L

(

% H

EA

LE

D)

Stage IIPU

Stage IIIPU

Stage IVPU

VenousUlcer

DiabeticFoot

Retrospective (n=120) TM + EB Practice (n=76)

0.0

5.0

10.0

15.0

20.0

25.0

WE

EK

S T

O H

EA

L

(

% H

EA

LE

D)

Stage IIPU

Stage IIIPU

Stage IVPU

VenousUlcer

DiabeticFoot

Retrospective (n=120) TM + EB Practice (n=76)

34%

83%

58%

57%

10%

36%

31%

55%

43%

56%

Depth: ThicknessDepth: Thickness Mean heal timeMean heal time % Healed in 12 % Healed in 12 weeksweeksPartial (N = 134) 31 days 61% Partial (N = 134) 31 days 61% Full (N = 373) 62 days 36%Full (N = 373) 62 days 36%

Pressure Ulcer Real-World Healing Outcomes Using Pressure Ulcer Real-World Healing Outcomes Using Evidence-Based, Validated AlgorithmsEvidence-Based, Validated Algorithms

507 Patients in Home TM, Long Term Care, Acute Care Clinic507 Patients in Home TM, Long Term Care, Acute Care Clinic11 Using pressure redistribution, less than 5% gauze dressingsUsing pressure redistribution, less than 5% gauze dressings

BenchmarkBenchmark

Best reported RCTBest reported RCTresults with Rx PDGF:results with Rx PDGF:23% of full-thickness23% of full-thicknesspressure ulcers healedpressure ulcers healedin 16 weeksin 16 weeks22

1Bolton L, McNees P, van Rijswijk L et al. JWOCN 2004; 31(3):65-7122Rees R. Wound Rep Reg, 1999, 7:141-147.

Venous Ulcer Real-World Healing Outcomes Venous Ulcer Real-World Healing Outcomes Using Evidence-Based, Validated Algorithms Using Evidence-Based, Validated Algorithms

154 Patients in Home TM, Long Term Care, Acute Care Clinic154 Patients in Home TM, Long Term Care, Acute Care ClinicUsing compression and less than 5% gauze dressings Using compression and less than 5% gauze dressings

Depth: ThicknessDepth: Thickness Mean + SE heal timeMean + SE heal time % Healed in 12 weeks% Healed in 12 weeksPartial (N = 30) 29 Partial (N = 30) 29 ++ 7 days 77% 7 days 77% Full (N = 124) 57 Full (N = 124) 57 ++ 7 days 44% 7 days 44%

Bolton L, McNees P, van Rijswijk L et al. Wound healing outcomes using standardized care JWOCN 2004; 31(3):65-71.

Implementing an adaptation of EB validated wound care guideline in Nova Scotia home care reduced time

and costs to healing or discharge to family care1

Implementing an adaptation of EB validated wound care guideline in Nova Scotia home care reduced time

and costs to healing or discharge to family care1

0

200

400

600

800

1000

1200

1400

1999 (6)

2000 (3)

2001 (33)

2002(435)

2003(250)

Ave

rage

Day

s to

Hea

ling

or T

o D

isch

arge

to F

amily

Car

e Pressure Ulcer

Venous Ulcer

Diabetic Foot Ulcer

Ischemic/Mix Ulcer

Surgical Wound

Burn Wound

Other Wound

0

200

400

600

800

1000

1200

1400

1999 (6)

2000 (3)

2001 (33)

2002(435)

2003(250)

Ave

rage

Day

s to

Hea

ling

or T

o D

isch

arge

to F

amily

Car

e Pressure Ulcer

Venous Ulcer

Diabetic Foot Ulcer

Ischemic/Mix Ulcer

Surgical Wound

Burn Wound

Other Wound

1Numbers in parentheses are total clients healed during specified year, not total receiving care.

(McIsaac C. O/WM 2005 Apr;51(4):54-6, 58, 59 passim. )

Hippocrates 460-400 BCELaw, Book IV

Hippocrates 460-400 BCELaw, Book IV

“There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance.”

“There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance.”