NEGLECTED TROPICAL DISEASES NTDs) uruli ulcer Buruli ulcer ...
Plymouth Health Community NICE Guidance Implementation Group Workshop Two: Debriding agents and...
-
Upload
dale-chandler -
Category
Documents
-
view
219 -
download
0
Transcript of Plymouth Health Community NICE Guidance Implementation Group Workshop Two: Debriding agents and...
Plymouth Health CommunityNICE Guidance Implementation
Group
Workshop Two: Debriding agents and specialist
wound care clinics. Pressure ulcer risk assessment & prevention
5th December 2002
Randomised Controlled Trial (RCT)
A trial in which subjects are randomly assigned to either a group receiving an intervention that is being tested or control group receiving an alternative or no intervention. The results compare the outcomes of the different groups.
Systematic Reviews
A review of research-based evidence on a topic in which the evidence has been systematically identified, appraised and summarised according to pre-determined criteria .
Plymouth Health CommunityNICE Guidance Implementation Group
Use of debriding agents & specialist wound care clinics for difficult to heal surgical wounds. Technology Appraisal Guidance (TGA 24).
Issue date: April 2001
Review date: March 2004
Background• Delays to healing caused by several
intrinsic & extrinsic factors - including debris within wound
• No reliable figures for wounds that become difficult to heal - 21,000 per year
• Trend towards community care• High levels of knowledge, skill & advice• Expert services for most intractable
Debridement
• Removal of devitalised necrotic or infected tissue or fibrin (‘debris’) from a wound
• Different methods of debridement, e.g. surgical, mechanical or autolytic
• Range of wound care products thought to promote autolytic healing: ‘modern dressings’
• Frequency of dressing change and patient acceptability important factors in choice of dressing
Cost to the NHS
• Actual costs of treating difficult to heal surgical wounds not been measured
• Health care costs not only unit costs of dressing used, but the frequency of dressing changes needed, over period of time. Nursing costs
• No. of patients affected not known, clinical practice varies. Difficult to estimate the cost and service impact on the NHS of changes in debriding agents or specialist wound care services.
Systematic review on effectiveness of debriding agents
To determine clinical and cost effectiveness of debriding agents in treating
surgical wounds healing by secondary intention
To evaluate the clinical and cost effectiveness of treating patients at
specialist wound care clinics, compared to conventional care
Types of evidence
Primary outcomes were wound healing and cost
• 17 trials selected all using autolyic method of debridement (13 surgical wounds)
•No studies investigated other types of debridement.
•No studies investigated specialist wound care clinics
Quality of evidence
Majority had methodological flaws:
• trials had small sample sizes (median: 43)• did not report randomisation or blinding
• did not report baseline characteristics
• did not report results in sufficient detail to calculate summary estimate of the treatment effect
•statistical tests used to compare the treatment groups often not reported, or no statistical test was used.
Findings of clinical effectiveness
Results should be interpreted with caution due to poor quality of the studies, unknown effects of potential confounding factors...
Clinical effectiveness
• No RCT evidence to support any
particular method of debridement
• Some evidence to suggest a
beneficial effect of modern dressings
for surgical wounds on other
outcomes, e.g. pain, dressing
performance and resource use. But
these outcomes difficult to assess and
subject to bias in unblinded studies
Cost effectiveness
• Four economic evaluations
• No evaluations comparing two
different types of modern
dressing, or of specialist wound
clinics
•Partial evidence to favour
modern dressings - lower costs
•Quality of effectiveness and cost
effectiveness analyses poor
Guidance• No evidence for particular method of
debridement. Modern dressings may
reduce pain and be acceptable to
patients
• Choice of debriding agent based on
impact on comfort, odour control and
other aspects relevant to patient
acceptability, wound type, and cost.
• Require structured approach to care
Implications for future research
• multi-centre trials comparing different types of modern dressing
• economic evaluations of modern dressings
•research into other debriding methods
•studies looking at the clinical & cost effectiveness of specialised wound care clinics
•epidemiological studies to evaluate the prevalence and cost to the NHS of treating such surgical wounds
Plymouth Health CommunityNICE Guidance Implementation Group
Pressure ulcer risk assessment and prevention. Inherited Clinical Guideline B
Issue date: April 2001
Review date: 2005
Evidence - linked information
• Identifying individuals at risk
• Use of assessment scales
• Recognising risk factors
• Skin inspection
• Pressure redistributing devices & use of aids
• Positioning & seating
• Education & training
Recommendations graded on their evidence base as follows:
1. Generally consistent finding in a majority of multiple acceptable studies
2. Either based on a single acceptable study, or a weak or inconsistent finding in multiple acceptable studies
3. Limited scientific evidence which does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality. Includes expert opinion.
i
Types of evidence
Two clinical issues subject of systematic review & provided evidence at level 1:-
1. risk assessment scales (McGough 1999).
2. pressure redistributing devices (EHCB 1995; Cullum et al. 2000)
• Most of the remaining evidence appraised at level 3
Quality of evidence
Both authors reported the poor quality of studies & trials available for review, e.g. lack of baseline comparability & poor descriptions of wound assessment, lack of blinding, inadequate sampling & attention to randomisation, inattention to inter-rater reliability etc,
Recommendations
Some research evidence that could be translated into recommendations:-
•Insufficient evidence to recommend using risk assessment scores - decisions made on holistic assessment of individual’s risk
•Individuals at risk should not be placed on standard foam mattresses
Guideline development
•Formal consensus development process to integrate the different evidence sources and, where there was a weak research base, agree recommendations based on current best practice. Appraisal of robustness of national guidelines.
Recommendations for future research
Potential future research agenda for pressure ulcer risk assessment and prevention is very large.
Attention to methodological standards
Need for well designed independent, multi-centred, randomised controlled trials re different types of pressure devices in variety of settings.