TPN

Discussion:

A previous study suggested that the implementation of guidelines changed both the clinical practice and outcomes of hospitalization dramatically.[1] Guidelines with a basis of the strongest evidence possible can also provide a means for standardizing and reducing costs of related health care.

Evidence-based medicine (EBM) has gained wide support for decision-making about many aspects of health care. The combination of the careful evaluation of evidence for validity and clinical applicability along with experience and expert consensus and opinion are used to build best practice guidelines. These guidelines seek to promote standardization, optimize performance, and improve outcomes. There are several definitions for EBM, such as this one from John F. Johanson, MD of the University of Illinois College of Medicine in Rockford, Illinois who states that EBM is the “conscientious and judicious use of current best research evidence in combination with clinical expertise and patient values applied to the management of individual patients.”[2]

Recommendations based on evidence are rated according to the level of support.[3]

Level A: Evidence obtained from at least one randomized controlled trial or meta-analysis of randomized controlled trials

Level B: Evidence from well designed clinical studies but no randomized controlled trials

Level C: Evidence from expert committee reports or opinion and/or clinical experience or respected authorities. Indicates absence of directly applicable studies of good quality

The basis for the best practices developed by the authors of this article is the Registered Nurses Association of Ontario’s (RNAO) guidelines, which included 65 recommendations[4] rated according to the scheme above in the categories shown in the table below.

Category/Recommendation (R) numbers	Recommendation summaries
Practice Recommendations
A. Assessment (R1-8)	Recommendations discuss the need for expertise in assessment, the use of a comprehensive clinical history and examination, documentation in structured format, examination of legs to determine venous and arterial diseases, measurement of ulcers at regular intervals, quality of life considerations, functional and other status of patient measures, and routine ulcer assessment.
B. Diagnostic evaluation (R9-12)	Recommendations discuss the specific diagnostic paths to determine causes and treatment possibilities.
C. Pain (R13-15)	Recommendations suggest the assessment, meaning, and management of pain.
D. Venous ulcer care (R16-26)	Recommendations discuss the specifics of wound care, including debridement, cleansing, dressings, topical products, moisture maintenance, allergic responses, use of compression hosiery, inappropriate use of biological wound coverings use of growth factor treatments, and optimization of nutritional status.

E. Infection (R27-32)	Recommendations address the assessment and treatment of wound infection.
F. Compression (R33-49)	Recommendations discuss appropriate use of compression therapies and systems as well as exercise.
G. Complementary therapies (R50-52)	Recommendations discuss the use of electrical stimulation, hyperbaric oxygen, and ultrasound therapies.
H. Reassessment (R53-54)	Recommendations outline routine assessment at intervals and reinforcement of teaching.
I. Secondary prevention (R55-56)	Recommendations suggest ways to prevent recurrence.
Education Recommendations
R57-63	Recommendations suggest ongoing education and training programs with specifics for educating health care professionals
Organization and Policy Recommendations
R64-65	Recommendations outline requirements for successful practice, including personnel and funding resources as well as involvement of qualified professionals and ongoing professional growth

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[1] Original guidelines issued in March 2004 are available at: http://www.rnao.org/bestpractices/PDF/BPG_venous_leg_ulcer.pdf

and the guidelines supplement that was issued in March 2007 is available at: http://www.rnao.org/Storage/30/2469_RNAO_Venous_Leg_Ulcer_Supplement.pdf.

[2] Timmerman T, Teare G, Walling E, Delaney C, Gander L. Evaluating the implementation and outcomes of the Saskatchewan Pressure Ulcer Guidelines in long-term care facilities. Ostomy Wound Manage. 2007;53(2):28-43.

[3] This is based on the information covered in Sacket DL, et al. Evidence based medicine: how to practice and teach EBM. London: Churchill-Livingstone, 2000.

[4] RNAO. Assessment and management of venous leg ulcers. 2004. Guideline Summary from the National Guideline Clearinghouse. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5309&nbr=&string=.