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Inclusion criteria for the data collection were records for adults 50 years of age or older with at least one documented wound and six months of available data. An exception to the length of records was made if the wound healing occurred more quickly. Records were excluded if there were only stage I pressure ulcers, concurrent cancer therapy, hemodialysis or kidney transplantation, and immunosuppressive therapy (including steroids). Data collected included demographics and clinical information that may affect risk for wounds and wound healing. Risk assessment scale scores and the ankle-brachial index were recorded. Information on wound characteristics, primary and secondary treatments, medication profiles, and outcomes were collected. The evaluation of records regarding the primary wound in a total of 400 patients with at least 3 months of information were included in the final analysis. The mean age was 73 years old. Most were Caucasian and females. Nearly half had venous ulcers (46%), followed by pressure ulcers (29%) and diabetic ulcers (26%). The level of adherence to wound care guidelines varied by type of wound and guideline. A summary of the findings are shown in the table below.
For venous ulcers the documentation of wound location and characteristics were fairly common (85% compliance with established guidelines), while other practices, such as cleansing (40-60%), debridement (51%), and dressings were less. Around 90% had documented orders for compression therapy, which was delayed in some cases up to two months. About 30% received ace bandage wraps and 16% received graduated multilayered compression systems. Complementary secondary therapies were used in 0.5-5% of cases and included hyperbaric oxygen, negative pressure wound therapy, growth factor and living skin equivalents. For diabetic ulcers, there were more varied results for documentation of location and wound characteristics (from 52-83% compliance with established guidelines). Offloading devices were documented in 77% of patients. A lower level of use of “modern dressings” was seen in diabetic ulcers at 42%, with 70% switched by the first month. The findings for pressure ulcers were similar with a relatively high level of compliance to guidelines in wound documentation and the lowest level of adherence in the dressings selected. The data suggested that assessment for wound characteristics were different for each clinical site. There were also differences in cleansing and pressure relief strategies. However, there were similarities in treatment approaches for the use of antibiotics and debridement between clinical sites. Non-modern dressings were fairly common. The authors suggested that compliance rates should be reflected in wound healing successes. This was true of the highest levels of compliance, but the clinical sites with lower levels of adherence to guidelines had differing results on wound healing results. Interestingly, even though one clinical site had the highest number of higher-risk patients, they did not have the lowest level of success. Summary: Evidence-based guidelines have been developed in an effort to improve health outcomes and costs of care. In this article, authors reviewed documentation of 400 patients receiving care for three types of wounds in four diverse geographical sites. Adherence was strongest for the location and documentation of wound characteristics and weakest for the use of modern dressings. Authors suggested that the lack of adherence on some aspects of wound characteristics may be related to a “lack of awareness or agreement” on documentation. High levels of adherence were seen for the ordering of compression and offloading therapies. Lower levels of adherence were seen for cleansing documentation. Dressing selection was the weakest area of adherence and authors suggested that modern dressings that could improve healing were not always used where indicated, which could have resulted in the numbers of wounds that worsened (6-25% across the sites). Incorrect use of modern dressings was noted in several cases. The authors suggest that there may be a mix of reasons, including lack of knowledge, availability, and reimbursement. The evaluation had mixed types of patients and mixed services in the various settings that could have contributed to the actual outcomes. In some sites there were wound care centers. Follow-up documentation ranged in frequency from weekly to 6-8 week intervals. Documentation may not have fully reflected care given and there were varying forms used of documentation that may have changed results. In addition, the authors noted that the knowledge of products and treatment varied between data collectors and could have affected the data collected. Translating evidence-based guidelines into clinical practice remains a challenge. The authors suggest that efforts to implement and test guidelines should be a priority in health care, especially considering the costs of wound care, both financially and by burden of effort. If efforts to improve care and outcomes, including costs, quality of life, and other outcomes are to be realized then adherence to guidelines and research to improve the quality of guidelines should be pursued. |
