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Considering the evidence for pressure injuries

Considering the evidence for pressure injuries. Andrew Jull Associate Professor, UoA Nurse Advisor, Quality, ADHB. What goes in a change package. Bundle acronyms often insufficient for identifying interventions SSKIN (Scottish change package) Surface selection Skin inspection Keep moving

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Considering the evidence for pressure injuries

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  1. Considering the evidence for pressure injuries Andrew Jull Associate Professor, UoA Nurse Advisor, Quality, ADHB

  2. What goes in a change package • Bundle acronyms often insufficient for identifying interventions • SSKIN (Scottish change package) • Surface selection • Skin inspection • Keep moving • Incontinence • Nutrition • What surfaces and when?

  3. Starting point Haynes RB. ACP Journal Club 2009;151(3):2-3.

  4. Guidelines • High level summaries • Information quality assessed • Recommendations graded by quality of evidence • A, B, C, D, CBR • Practice points (consensus)

  5. Surface selection when at risk At Risk of PI Use a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for patients at risk of pressure injuries. Graded A At high risk of PI Active (alternating pressure) support mattresses could be used as an alternative in patients at high risk of pressure injuries. Graded A Evidence sourced from Cochrane review

  6. Using imperfect information • Trials of both devices compared to standard hospital mattresses • Trials recruited patients at high risk of PI to both devices • Interpretation and consensus needed • Use less expensive device with lower risk • More expensive device with higher risk

  7. Evidence gap • High spec foam vs AP mattress • RCT of alternating pressure overlay vs high spec foam mattress (and Q4 turning) • Not included in GL • Unfair comparison? Repositioning in one group but not in the other. Or does it model clinical practice?

  8. Surface selection if has PI Manage patients with existing pressure injuries on a high specification reactive (constant low pressure) or active alternating pressure) support surface on beds and trolleys and when seated. Grade A • Evidence drawn from same source as when patient at risk or higher (not patients with PI) • If patient has PI are they not at high risk and thus above recommendation soemwhat inconsistent with previous recommendation?

  9. Limitations of guideline • Data source systematic reviews or previous guidelines • Currency of evidence • Missed RCTs of recent evidence • Heel off-loading devices • Curious re-interpretations • Honey

  10. Heel off-loading devices (HOLD) Any device used to prevent heel pressure injuries should be selected and fitted appropriately to ensure pressure is adequately offloaded. Graded CBR (consensus-based recommendation) • Missed reasonable quality RCT that showed 19% reduction in all PIs when HOLD used in addition to pressure-redistributing surfaces Donnelly J et al. J Wound Care 2011;20:309-18.

  11. Honey as wound dressing • Systematic review found one trial comparing honey to saline dressings • Review finding • The effect of honey on pressure ulcers cannot be determined from the single trial • Guideline recommendation • Consider using topical medical grade honey to promote healing in pressure injuries Grade D Jull A, et al. Cochrane Database Sys Rev 2008.

  12. Other idiosyncrasies

  13. Systematic reviews • Cochrane database the best source of SRs • Access free via www.nzgg.org.nz • Other SRs published • Require own quality check

  14. Quick quality assessment • Does it have an objective • Does it use exhaustive searches • Does it quality assess studies • Does it use processes to reduce bias • More than one person checking processes • Does it assess publication bias • Positive studies more likely to be published

  15. Sheepskins • “Medical grade” sheepskin • Four RCTs • Incidence halved in sheepskin group • No cost-effectiveness information • If evidence accepted, questionable whether feasible in acute care setting • May be more feasible in residential care setting?

  16. AP Mattress vs AP overlay • Large high quality RCT & cost-effectiveness study • No difference in incidence of Grade≥2 PI • Small difference in number requesting change in device (19% vs 23%) • Mattresses more cost-effective due to longer time to development of PI • 10.6 days longer to develop PI

  17. Individual studies • Type of study important • Privilege RCT over other designs • Require own quality check • Tools available • CEBM-type CAT (http://www.cebm.net/?o=1216) • GATE (http://www.fmhs.auckland.ac.nz/soph/depts/epi/epiq/ebp.aspx)

  18. Information rarely perfect Clear answer to clinical need in all or even specific circumstances not common What to include in change package will almost always require interpretation and consensus Agreement on sources of information, but be aware of source’s idiosyncrasies Conclusion

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