Prof. Seamus Cowman Royal College of Surgeons in Ireland December 2005

1. Irish Evaluation Network Finding and Using Evidence: The Healthcare Experience Prof. Seamus Cowman Royal College of Surgeons in Ireland December 2005

2. How do we know what we do and the decisions we make are derived from best practice? The importance of evidence in making decisions Determine a process of finding and validating knowledge for use in day to day activities Research based knowledge is fundamental to effectiveness and valid and reliable outcomes Central thesis of the paper

3. Evaluation: what is said A means of systematically collecting and analysing of information. Purpose of evaluation is to improve effectiveness – activities and outcomes Necessary not only to improve practice but prove it Inevitably concerned with decision making Evaluation finding and using evidence – the links

4. Decision making often based on values and opinion: Confusion about best practice The Importance of Evidence

5. Public Expectation & Consumerist ethos Quality Assurance, User Satisfaction Accountability and efficient use of available resources The Importance of Evidence

6. Patients as informed consumers want more, expect more and complain more The Importance of Evidence

7. Research utilisation is a ‘systematic method of implementing sound, research based innovations in clinical practice, evaluating the outcomes and sharing the knowledge through the process of research dissemination.’ (LoBiondo-Wood & Haber, 1994) Research Utilisation

8. Unsatisfactory Why? Lack of focus on outcomes research Inadequate dissemination of research findings Failure to maximise potential avenues for dissemination eg; on line, Internet, Intranet Research Utilisation

9. Policy makers rarely signal a demand for research, many appear allergic to research and pay lip service to evidence based policy; even when there is an appetite for change Pestieau 2003 Research Utilisation

10. It has proved difficult to uncover many instances where social sciences research has had a clear and direct influence on policy even when it has been specifically commissioned by government Quinn Patton 1997 Research Utilisation

11. Communication gap between researcher and practitioner Findings communicated primarily to other researchers Practitioner may not value research findings Barriers to Research Utilisation

12. Researcher originated studies Policy making perceived exclusively as an art rather than a science. Practitioners and decision makers do not know how to apply research findings Barriers to Research Utilisation

13. In a study with medical doctors, therapy issues and critical appraisal of literature on appropriate clinical practice only 5 out of 36 searched the Cochrane library, appraisals were sometimes inaccurate. When article was retrieved for appraisal usability was found to be high www.jrsm.org/cgi/content/full/94/11/573 Information Retrieval

14. In a nursing study it was reported that it is not the research knowledge per se that carries little weight in the clinical decision making process but rather the medium through which it is delivered and the process of retrieval (Thompson et al 2001) Information Retrieval

15. The average time span between discovery and utilisation is 20 years Decrease in time for utilisation of discoveries 1185 - 1919 30 years 1945 – 1965 17 years The Time Lag

16. The Time Lag (Glaser et al 1983) Putting knowledge to use Jossey Bass.

17. Collaborate with Practitioners Disseminate Research Findings Aggressively Communicate in a way comprehensible to non researchers Suggest practical implications, how can findings be utilised Message for Researchers

18. Read widely and critically online searching of www and data bases – Start up a Journal Club: Create a learning culture Attend professional conferences/seminars Learn to expect evidence that a procedure is effective Collaborate with researcher Participate/initiate institutional projects Message for Practitioners/decision makers

19. Foster a climate of intellectual curiosity Offer support and facilitation to researchers Offer financial support and resource support for utilisation Reward efforts of research utilisation Support an Evidence Based Practice culture Message for Administrators

20. Finding Best Evidence • Too much information available • Literature reviews can be biased Cochrane Collaboration (2003)

21. Finding Best Evidence • Publication Bias • Time lag bias • Multiple (duplicate) publication bias • Citation bias • Language bias • Outcome reporting bias • Systematic reviews attempt to minimise bias and provides confidence with the use of knowledge. Egger et al, (2001)

22. Finding Best Evidence Case Study A Practical Problem becomes a Cochrane Review . Egger et al, (2001)

23. Pressure Ulcer

24. Pressure Ulcer

25. Pressure Ulcer

26. The Importance of Research Evidence An EU study found that 18% of hospital patients had a pressure ulcer (EPUAP 2002) Cost of Pressure Ulcer management in the UK estimated to be £1.4 - 2.1 billon (4% total healthcare budget).

27. Objective of Systematic Review To assess the effects of wound cleansing solutions and techniques on the healing rates of pressure ulcers

28. Cochrane Database The Cochrane library contains 2,500 reviews. – Randomised Control trials (RCTs) A data base of evidence about different interventions It assess intervention across all areas of health care and brings together sufficient research evidence to draw conclusions about the effects of an intervention.

29. A Systematic Review A way of Finding, Assessing, and Using evidence from studies (usually RCTs) to obtain a reliable overview Cochrane Collaboration (2003) Finding the Evidence

30. Types of Study included in Review • RCT's comparing wound cleansing with no wound cleansing • RCT's comparing different wound cleansing solutions • RCT's comparing different wound cleansing techniques • No restrictions regarding year or language of publication

31. Type of Participant Studies involving people of any age, in any health care setting, with existing pressure ulcers (defined as a break in the continuity of the skin caused by pressure with or without shearing/friction forces)

32. Type of Outcome Measure - Primary • An objective measure of pressure ulcer healing • Time to complete healing • Rate of change in pressure ulcer area or volume • Proportion of pressure ulcers healed

33. Type of Outcome Measure - Secondary • Pain, using validated scales where reported • Ease of use of the method of cleansing • Secondary outcomes only reported from studies which also report primary outcomes

34. Search Strategy • Cochrane Central Register of Controlled Trials (CENTRAL) • Specialised Trials Register of the Cochrane Wounds Group (up to August 2005) • Hand search of relevant bibliographies • Contacted experts and researchers in the field

35. Data Extraction & Analysis • 2 authors extracted data independently • Structured narrative summary initially • Data entered into Cochrane RevMan 4.2 and analysed with Cochrane MetaView. • For dichotomous outcomes RR & 95% CI calculated • For continuous outcomes WMD & 95% CI calculated • Meta analysis not conducted due to small number of diverse RCT’s

36. Data Extraction Criteria • Were the eligibility criteria clearly specified • Was the generation of the randomisation truly random • Was the allocation to treatment group concealed • Were the groups similar at base line in term of prognostic factors • Were outcome assessors blinded to treatment allocation • Were measures of variability for each group presented for the primary outcome measure • Were participants analysed in groups in which originally allocated.

37. Initial search 111titles 33 letters written 13 replies received no new studies Abstracts reviewed 12 papers possibly eligible Inclusion Criteria applied 3 papers eligible

38. Results

39. Methodological Quality

40. Conclusion Overall, there is no good trial evidence to support use of any particular wound cleansing solution or technique for pressure ulcers

41. Reflections • 19 months work • Greatest challenge lay in the lack of clarity in publications • Lack of data a disappointment

42. Moore Z., Cowman S. Wound cleansing for pressure ulcers. The Cochrane Database of Systematic Reviews 2004, Issue 4, Art, No.: CD004983. DO1: 10.1002/14651858.CD004983. Cochrane Review