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Developing a Comprehensive Content Validated Pressure Ulcer Guideline. Association for the Advancement of Wound Care Wound Care Specialty Clinical Section, Guideline Department (GD) http://www.aawconline.org/ Co-chairs: Susan Girolami, RN, BSN, CWOCN & Laura Bolton, Ph.D.

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Developing a comprehensive content validated pressure ulcer guideline l.jpg
Developing a Comprehensive Content Validated Pressure Ulcer Guideline

Association for the Advancement of Wound Care

Wound Care Specialty Clinical Section,

Guideline Department (GD)

http://www.aawconline.org/

Co-chairs: Susan Girolami, RN, BSN, CWOCN & Laura Bolton, Ph.D.

Mona Baharestani, PhD ANP CWOCN CWS

Teri Berger, RN, CWCN

Linda Foster, RN, BSN, CWCN

Roslyn Jordan, RN, BSN, CWOCN

Sofia Kahn, MD, MBBS, MGenSurgery

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


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AAWC Wound Care Specialty Council Clinical Section, Guideline Department

Multi-disciplinary All-Volunteer Guideline Department (GD) Team

Mission

Develop, optimize and maintain guidelines based on best available evidence to improve wound care practice, and serve as a liaison for other guideline initiatives.


Background pressure ulcers pu l.jpg
Background: Pressure Ulcers (PU) Guideline Department

  • Incidence and costs of PU in USA

    • 280,000 hospital in-patients in 1993 rose 63% to 455,000 in 20031

    • 257,412 Stage III / IV PU Medicare patients cost >$11 B in 20072

  • Heavy clinical and caregiver burdens, worse in elderly

    • 72.3% of hospital in-patients with a PU were > 65 years of age1

  • PU reduce quality of life, increase costs of care

    • $37,800 mean charge/hospital stay principally for PU1

  • Evidence-based care heals most Stage II PU in < 12 weeks3,4

  • Inconsistent protocols of care impair PU prevention and healing efforts5

1Healthcare Cost & Utilization Project, AHRQ, 2006

2CMS, 2007

3Kerstein M. et al. Dis Management Health Outcomes, 2001, 9(11):651-636.

4Bolton L, McNees P, van Rijswijk L et al. JWOCN 2004; 31(3):65-71

5Bolton L., et al.Ostomy/Wound Management 2008; 54(11):22-30.


Slide4 l.jpg

Figure 1. Prospective Cohort Study Guideline DepartmentMore PU healed faster using consistent, evidence-based protocols than retrospective same-agency controls.

(10%)

(58%)

(36%)

  • Healing: 42% healed in each group (p=0.627)

  • Velocity of area (p=0.43) and depth (p=0.09) reduction were similar

  • Greater total ulcer depth reduction in AQAg group (Fig.1; p= 0.042)

(57%)

(34%)

(83%)

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


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Figure 2. PU Cohort Using Evidence-Based Protocols Guideline Department

In Home Care, Long Term Care, LTAC (N = 507)1

Depth: Thickness (th)Mean + SE heal time% Healed in 12 weeks

Partial-th.(N = 134) 31 + 5 days 61%

Full-th. (N = 373) 62 + 4 days 36%

1 Bolton L, McNees P, van Rijswijk L. et al.JWOCN 2004; 31(3):65-71


Figure 3 cohort study pressure ulcer prevention using evidence based skin care in long term care 1 l.jpg
Figure 3. Cohort Study: Pressure Ulcer Prevention Guideline DepartmentUsing Evidence-Based Skin Care in Long Term Care 1

P = 0.02

August 1999

December 1999

1 Lyder C et al.Ostomy / Wound Management 2002; 48(4):52-62.


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Rationale: The brewing PU storm Guideline Department

  • Professionals and institutions are held accountable for PU development and management.

  • Consistent evidence-based management improves PU incidence and outcomes.

  • Differences among PU protocols and guidelines confuse caregivers reducing consistency and quality of care and outcomes.


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Objectives of AAWC Guideline DepartmentPressure Ulcer Care Initiative (PUCI)1

  • Evaluate current PU guideline recommendations

    • to assess need for one comprehensive, content-validated PU guideline1

  • Compile content validated unified list of all current PU guideline recommendations

  • Provide best evidence for each recommendation

    • to empower PU professionals and caregivers

1Bolton L., et al.Ostomy Wound Management 2008; 54(11):22-30.


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AAWC Pressure Ulcer Care Initiative (PUCI): Methods Guideline Department

  • Timeline: January, 2008 - February, 2009

    • Guideline and literature searches: Jan-Oct, 08

    • Compile, simplify published PU guideline items: Feb-Nov 08

    • Content validate PUCI recommendations: Nov 08-Feb 09

    • Annotate recommendations with best evidence: Feb 08-ongoing

  • Funding: No industry funding to date

    • AAWC provided meeting room at SAWC08 and

    • AAWC connections for 12 teleconferences

  • Personnel: Volunteer AAWC-Member Guideline Team:

    • 4 CWOCNs

    • 3 CWCNs

    • 2 Physicians

    • 2 Physical Therapists (1 with PhD)

    • 2 PhDs


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AAWC PUCI: Methods Guideline Department

  • AAWC PUCI Content Validation Survey

    • Each recommendation rated for clinical relevance

      1 = Not relevant

      2 = Unable to assess relevance without further information

      3 = Relevant but needs minor attention

      4 = Very relevant and succinct

  • Evidence from MEDLINE, EMBASE searches

    • AHRQ (former AHCPR) criteria forlevels of evidence

      Level A: At least 2 human pressure ulcer RCTs

      Level B: > 2 human PU non-randomized CTs or one plus a RCT

      Level C: Less than 2 controlled trials; opinion or case series

    • Each PUCI recommendation annotated with best 3 studies


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AAWC PUCI: Results to date Guideline Department

  • Compiled 380 recommendations from:

    • 10 National Guideline Clearinghouse PU guidelines

    • Wound Healing Society PU guideline

    • Draft NPUAP, EPUAP PU guidelines


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Differences Guideline Department

Implications for Practice

Definitions

Improper or inconsistent staging, documentation affects outcomes and related reimbursement

Procedures

Inconsistent measurement and monitoring of progress delays recognition of impaired healing

Content

Effective interventions: Support surfaces? Nutrition? Care may be inconsistent if content is not uniform.

Focus

Provider focused content: e.g. RN, PT. Patient focus improves PU prevention, diagnosis and care.

Evidence

Level A ranged from 2 human PU RCTs to animal studies. Inconsistent clinical relevance of evidence.

Validation

Content validation adds validity and clarity to recommendations, reducing legal liability.

Example Guideline Differences


Example differences in pressure ulcer measurement methods l.jpg
Example Differences In Guideline DepartmentPressure Ulcer Measurement Methods

Geometric (longest length x longest perpendicular width) measurements validated as an effective measure of total wound area and as a strong predictor of wound healing(p<0.05; n =260 wound patients)1

1Kantor J, Margolis DJ. 1.Arch Dermatol 1998; 134: 1571-1574.

  • Ulcer orientation may change over time increasing error of Body Axis measurements e.g. head-toe may not be longest length. Geometric method avoids this error improving ability to monitor pressure ulcer progress:

  • Across care settings

  • During each episode of care

Geometric Method of Measuring PU Length and Width


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AAWC PUCI Content Validity Survey Guideline DepartmentSurvey and Respondent Characteristics

  • Content validation survey to1700 AAWC members + 40,000 readers of O/WM, open to all.

  • Clinical relevance ratings of recommendations

    • 1 = Not relevant

    • 2 = Too confusing to decide

    • 3 = Relevant, need to improve

    • 4 = Relevant and succinct

  • Respondents: N= 31 (26 female, 5 male)

    • 20 Nurse professionals (10 WOCNs, 1 NP, 1 CWCN)

    • 6 Physical Therapists

    • 2 Physicians (Physiatrist, Plastic Surgeon)

    • 2 Ph. D.

    • 1 Podiatric specialist

  • Most time spent in acute inpatient (61%) or outpatient (33%) care, home care (55%), office practice (50%), or group practice (33%)


  • Slide15 l.jpg

    Results: Mean Content Validity Index (CVI): Section 1: Guideline DepartmentPatient and PU Assessment Parameters (Part 1) Items with Content Validity Index < 0.750 Require A-Level Evidence to Keep

    • Assessment ParameterMean C. V. I.

    • Risk assessment 0.922

    • Nutritional 0.897

      • Anthropometric BMI (0.710)

    • Medical/surgical history 0.956

    • Psycho-social/quality of life 0.750

      • Sexuality (0.233)

      • Culture / ethnicity (0.433)

      • Polypharmacy (0.742)

      • Vocational rehab. (0.433)

      • Peer counseling (0.300)


    Slide16 l.jpg

    Results: Mean Content Validity Index (CVI): Section 1: Guideline DepartmentPatient and PU Assessment Parameters (Part 2)Items with Content Validity Index < 0.750 Require A-Level Evidence to Keep

    • Assessment ParameterMean C. V. I.

    • Environmental 0.880

      • Obtain fall history (0.742)

    • Physical exam 0.925

      • Halogen light: skin (0.379)

      • PU length, width

        • Geometric (0.742)

        • Anatomic (0.677)

    • Diagnostic tests 0.897

    • Documentation 0.935


    Slide17 l.jpg

    Results: Mean Content Validity Index (CVI): Section 2: Strategies for PU Prevention and Preventing PU RecurrenceItems with Content Validity Index < 0.750 Require A-Level Evidence to Keep

    • Prevention ParameterMean C. V. I.

    • Skin inspection & maintenance 0.919

      • Use perineal antimicrobial cleanser (0.677)

      • Use nonionic to replace anionic surfactants (0.667)

    • Hydration & nutrition plan of care 0.941

    • Rehabilitative & restorative programs 0.927

    • Position to manage pressure, shear, friction 0.972

    • Off-loading beds, chairs, OR equipment 0.935

    • Interdisciplinary approach 0.952

    • Education 0.966


    Slide18 l.jpg

    PUCI Results: Guideline Section 3. Strategies for PU Prevention and Preventing PU RecurrenceMean CVI of Pressure Ulcer Treatment Strategies (Part 1)Items with Content Validity Index < 0.750 Require A-Level Evidence to Keep

    • PU Treatment StrategyMean C. V. I.

    • Implement, continue PU prevention 0.967

  • Remove or alleviate PU causes 0.935

    • Manage local & systemic factors 0.896

      • Debridement

        • Mechanical with gauze (0.733)

        • Laser (0.500)

        • High flow irrigation (0.700)

        • Whirlpool (0.433)

        • Biological with maggots (0.700)

      • Wound Cleansing with hydrotherapy (0.552)

      • Hydrocolloid dressing cost effective (0.710)


  • Slide19 l.jpg

    PUCI Results: Guideline Section 3. Strategies for PU Prevention and Preventing PU RecurrenceMean CVI of Pressure Ulcer Treatment Strategies (Part 2) Items with Content Validity Index < 0.750 Require A-Level Evidence to Keep

    • PU Treatment StrategyMean C. V. I.

    • Advanced, adjunctive PU modalities 0.777

      • UV light/phototherapy (0.533)

      • Pulsed Electromagnetic (0.517)

      • Growth factors (0.645)

      • Topical phenytoin (0.250)

      • Topical estrogen (0.185)

      • Infrared stimulation (0.393)

      • Pedicle grafts (0.690)

    • Document management & outcomes 0.968

    • Provide appropriate palliative care 0.961


    Conclusions l.jpg
    Conclusions Strategies for PU Prevention and Preventing PU Recurrence

    • Diverse guideline recommendations reduce consistency of PU care, confuse professionals and diminish outcomes.

    • To improve PU care consistency and outcomes AAWC GD tested content validity of published PU recommendations

    • Most recommendations had strong content validity (> 0.90)

    • Areas of confusion included some aspects of:

      • Psycho-social/quality of life

      • Skin and pressure ulcer evaluation

      • Skin and pressure care modalities for:

        • Cleansing

        • Debridement

        • Advanced adjunctive therapies

    • Next steps:

      • AAWC GD compile evidence supporting all recommendations

      • Retain recommendations with A-level evidence and/or CVI > 0.75


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