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Evidence-Based

Practice

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EBP

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

Terminology/Abbreviations

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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)

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 frustration and time constraints.

Despite our best efforts, we frequently miss the most current research and dynamics within technology. Now is the time that nurses discover new options.

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Evidence-Based Practice (EBP)

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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 DFUsOutcome: at least one specific outcomes

P I C O

Phase 2:

Validation

a. Synthesis summary

b. Grade and evaluate strength of evidence from articles

Phase 3:

Comparative 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 Applicationa. Findings be used?

b. Protocol implement findings

c. Are there implications for practice?

Phase 6:

Evaluationa. Clarify anticipated outcomes

b. How exactly will protocol be evaluated

c. Will data be used to evaluate care8

Stetler Model

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 SummaryVacuum 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 infectionsØ Increased amount of ulcers healed in less time Ø Additional Quality Adjusted Life-Years (QALYs)Ø Lower cost, specifically due to decreased need of nursesØ 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 EvaluationØ 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/ApplicationPhysicians, 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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EvaluationWhen 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.

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

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.

Negative Pressure Wound Therapy (NPWT) or Vacuum-assisted Closure (VAC) Therapy

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Evidence-based Practice1

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Never cease to assess the need to make any changes or to stop evaluating what you find.

EVIDENCE-BASED PRACTICE

Amber Huett and David MacMillan June 2011 UNA Center for Writing Excellence 1

Evidence-Based Practice in nursing focuses on the idea that medical practices ought to be developed and adapted based on an ongoing cycle of evidence, theory, and research. As changes in practice prompt further research, the theories developed from that research serve as evidence to produce more changes in practice. The implementation of Evidence-Based Practice in nursing, also called Systematic Review, requires the review of such research with the intention of targeting and improving inadequate practice.

The systematic review of outside research attempts to make sense of the large body of information available in order to implement change effectively. The available research may be qualitative, quantitative, or evidence-based. How can this research be applied on an individual basis to improve patient care?

Evidence-Based Practice involves the following six steps:

1. Assess the need for change: Formulate the research question based on the inadequacies of current practice.

2. Locate the best evidence: Obtain sources and assess their credibility and relevancy to the research question.

3. Synthesize evidence: Compare and contrast the available sources to find similarities and differences in the various approaches taken.

4. Design the change: Apply the synthesized evidence to create a change in practice that reflects the new understanding.

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 x Collect internal data on current

practice x Link problems, interventions, and

outcomes

Step 2 x Identify sources of evidence x Refine research strategy x Conduct the research

Step 3 x Appraise the value of the

evidence x Synthesize the best evidence x Assess the risks and benefits of

the new practice

Step 4 x Define proposed changes x Identify the necessary resources x Design the implementation

Step 5 x Implement the proposed

changes x Evaluate process and outcome x Generate conclusions

Step 6 x Recommend broader changes x Integrate changes into standards

of practice x 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 fromhttp://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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