Translation from guideline recommendations into clinical practice is important to improving patient care. The third paper (Jones et al) reviewed documentation on the actual management of chronic wounds in several settings and geographically diverse areas to determine how well guideline recommendations were met. There were several difficulties encountered in gathering data for this evaluation. The different types of documentation used in the various facilities and the lack of documentation, particularly on specific wound characteristics and care procedures. It appeared that the results were dependent on both the institutions and settings where the documents originated and the type of ulcers that were addressed. For instance, documentation may have been more complete in wound care centers than in less specialized settings. Documentation may also have been incomplete because of the wide number of referrals for various aspects of care and the separation of the documents for each specialist. The areas of most obvious weakness included appropriate choices in dressings and changes in dressings within a month or so of initiation of those orders. Because of the cost of dealing with chronic wounds in many health care settings, it seems appropriate to dedicate effort and resources to train care providers on guidelines and recommendations for the improvement of care and outcomes. This article demonstrated the need for standardization of efforts to improve successful wound healing and reduction of adverse outcomes.

In the fourth paper (Thomason et al) a survey and series of focus groups were conducted to determine the barriers to the implementation of a selected guideline for wound care. Physician and nurse participants were asked if they agreed or disagreed with the guideline and why. Responses showed that physicians agreed more often with the guidelines and stated that they were more completely implemented in their facilities than did the nurses. While this could have something to do with their various job duties, it also suggested a number of barriers to implementation related to organizational support, education and training, resources, design and wording, and level of evidence. The results pointed to the need to have simple and carefully worded guidelines based on stronger evidence that are realistic and can be adopted given the resources available.

In the fifth paper (Alvarez et al) authors suggested the integration of symptom management efforts into standardized care to better meet the needs of palliative care patients. Beyond the standard guidelines, the authors recommended efforts that concentrated on patient comfort and emphasis on meeting care plan goals within the palliative care setting. Authors gave practical advice, such as using slider sheets to reduce pain in turning patients or the use of particular devices that may provide more comfort to patients. In addition, it was noted that even though palliative care may be emphasized with the patient, the goal of care should still be full wound healing wherever possible. Adjunctive therapies, such as physical therapy for contractions and nutritional supplements to improve health status and support wound healing were suggested. Different types of wounds had different treatment recommendations, as with any of the existing guidelines. However, the integration of symptom management efforts altered the more general recommendations to emphasize pain management, patient comfort, and reduction of wound odor. Each of these efforts could lead to better wound management in this population of patients.

The articles reviewed in this journal club ranged from literature reviews and evidence-based guidelines to an examination of the challenges of implementation and the integration of palliative patient care. While literature reviews give a starting point for appropriate clinical management, evidence-based guidelines help to establish a wider range of recommendations for successful wound care. However, the guidelines that currently exist remain difficult to critically evaluate and implement. The evaluation of evidence has not been standardized, so it is difficult to compare one set of guidelines to another. For instance, the guidelines reviewed in the first article suggest that a recommendation has “level A” evidence if there is at least one randomized trial to support it. However, the guidelines reviewed in the second paper suggests that “level A” evidence requires two or more randomized controlled trials on humans at levels I or II of evidence quality, meta-analysis of randomized clinical trials, or a Cochrane Systematic Review of randomized clinical trials. The “level B” criteria are similar to “level A” in the first paper, which requires one or more controlled trials. Considering that the challenges in implementing guidelines includes the lack of adequate evidence, it would be helpful to have standardized levels of evidence presented in guidelines, particularly when dealing with similar topics around wound care. Guidelines should consider practical aspects of implementation, including realistic expectations of resources, training, and considerations for different populations at high risk for developing wounds.

You may now continue on to the Post-Test by clicking on the link below: