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Diabetes/metabolism Research and Reviews Mar 2024Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are...
AIMS
Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.
MATERIALS AND METHODS
We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.
RESULTS
From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.
CONCLUSIONS
These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.
Topics: Pregnancy; Female; Humans; Diabetic Foot; Placenta; Foot Ulcer; Wound Healing; Diabetes Mellitus
PubMed: 37232034
DOI: 10.1002/dmrr.3644 -
Diabetes/metabolism Research and Reviews Mar 2020Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of...
Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non-controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot-related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight-bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non-existent for the prevention of a first foot ulcer and non-plantar foot ulcer.
Topics: Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Foot; Disease Management; Humans; Patient Compliance; Patient Education as Topic; Practice Guidelines as Topic; Practice Patterns, Physicians'
PubMed: 31957213
DOI: 10.1002/dmrr.3270 -
International Journal of Nursing Studies Feb 2020Pressure injuries are potentially preventable but frequently occurring adverse events. Intensive care patients have major risk factors for pressure injury with a...
BACKGROUND
Pressure injuries are potentially preventable but frequently occurring adverse events. Intensive care patients have major risk factors for pressure injury with a reported pressure injury prevalence of 12-33%. Multi-faceted interventions, also known as programs or care bundles, are recommended to prevent pressure injuries.
AIM
This systematic review evaluated the effectiveness of pressure injury prevention programs in reducing pressure injury prevalence and incidence in the adult intensive care population. It also critically appraised the program components and strategies used to implement these programs.
METHOD
We searched PubMed, EMBASE (embase.com), Ovid MEDLINE, EBSCOhost CINAHL, and Cochrane Library databases separately for papers published in English and Chinese from the year of 2000 to May 2018. After removing duplicates, two authors independently screened the title and abstracts, then full-text against the inclusion and exclusion criteria. Data was extracted by one author and checked by a second author. Quality appraisal was conducted by two authors by using the Quality Improvement Minimum Quality Criteria Set, and the Mixed Methods Appraisal Tool. Content analysis was used to categorise program components. Implementation strategies were grouped into six classifications: dissemination strategies, implementation process strategies, integration strategies, capacity building strategies, sustainability strategies, and scale up strategies.
RESULTS
Twenty-one peer reviewed papers (12 quality improvement projects, and 9 research papers from 8 studies) were included. Pressure injury prevention programs with 2-11 components were commonly implemented. Common components of the programs included: clarification of staff roles, introducing new roles, repositioning, staff and patient education, support surfaces use, pressure injury risk assessment, skin assessment, nutrition needs assessment, documentation, multidisciplinary team involvement, and mobilisation. Implementation strategies commonly used were education, audit and feedback, and standardising documentation. Five of the eight research studies and one of the quality improvement projects reported significant decrease in pressure injury prevalence, and/or increase in compliance to pressure injury prevention protocols and strategies. Two quality improvement papers reported cost savings of $1 million and £2.6 million respectively after the implementation of the programs.
CONCLUSION
Much of the work on multicomponent pressure injury prevention programs has been undertaken as quality improvement projects and before and after research studies with limited rigour. However, positive outcomes and strong theoretical rationales for the components in the programs suggest that they are beneficial. This calls for future high-quality research such as randomised controlled trials to test the effectiveness of multicomponent interventions and their implementation strategies. Tweetable abstract: Some multicomponent pressure injury prevention programs were found to be effective; however, higher level of research evidence is needed.
Topics: Adult; Combined Modality Therapy; Critical Care; Guideline Adherence; Humans; Pressure Ulcer; Quality Improvement; Risk Factors
PubMed: 31835122
DOI: 10.1016/j.ijnurstu.2019.103483 -
Journal of Wound Care Sep 2020Chronic wounds affect an estimated 2.21 per 1000 population. They are a significant source of morbidity and affect individuals physically, psychologically, socially and...
BACKGROUND
Chronic wounds affect an estimated 2.21 per 1000 population. They are a significant source of morbidity and affect individuals physically, psychologically, socially and financially. Person-centered care is one approach to improve patient outcomes in wound care as it values patients' perspectives, beliefs and autonomy and considers the person as a whole within the cultural context in which care is provided.
AIM
We aimed to review the evidence on the use of person-centered care (PCC) in chronic wound care management and provide recommendations for practice and future research.
METHOD
Using a systematic review methodology, we searched six databases for full-text papers from 2009-2019 published in peer-reviewed journals with no limits on language.
RESULTS
Eighteen articles on studies involving 3149 patients from nine countries were identified. Studies were conducted under three broad intervention categories: healthcare professional education (n=1); patient education (n=14) and telemedicine (n=3). Studies were equally focused on prevention and treatment of chronic wounds. Significant improvements were reported in patient knowledge, pain and self-care behaviours. Only two studies evaluated the impact on wound healing and one study estimated the cost of implementing person-centered care.
CONCLUSIONS
The evidence base to support PCC in wound management is developing and based on our review has shown improved outcomes in areas of pressure ulcer prevention, patient satisfaction, patient knowledge and quality of life, but clinical outcomes such as wound healing were less well explored. Further research with more objective outcome measures are required.
Topics: Humans; Patient Satisfaction; Patient-Centered Care; Quality of Life; Telemedicine; Wounds and Injuries
PubMed: 32935648
DOI: 10.12968/jowc.2020.29.Sup9b.S1 -
Journal of Advanced Nursing Dec 2019To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.
AIMS
To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.
DESIGN
A quantitative systematic review included studies published in English between January 2000 - September 2018.
DATA SOURCES
Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.
REVIEW METHODS
The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.
RESULTS
Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.
CONCLUSION
Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.
IMPACT
Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.
Topics: Clinical Competence; Humans; Nurse-Patient Relations; Nursing Staff, Hospital; Treatment Outcome
PubMed: 31483509
DOI: 10.1111/jan.14194 -
The Cochrane Database of Systematic... Oct 2022There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as... (Review)
Review
BACKGROUND
There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as repositioning, to reconstructive surgery. The surgical approach is usually reserved for recalcitrant wounds (where the healing process has stalled, or the wound is not responding to treatment) or wounds with full-thickness skin loss and exposure of deeper structures such as muscle fascia or bone. Reconstructive surgery commonly involves wound debridement followed by filling the wound with new tissue. Whilst this is an accepted means of ulcer management, the benefits and harms of different surgical approaches, compared with each other or with non-surgical treatments, are unclear. This is an update of a Cochrane Review published in 2016.
OBJECTIVES
To assess the effects of different types of reconstructive surgery for treating pressure ulcers (category/stage II or above), compared with no surgery or alternative reconstructive surgical approaches, in any care setting.
SEARCH METHODS
We used standard, extensive Cochrane search methods. The latest search date was January 2022.
SELECTION CRITERIA
Published or unpublished randomised controlled trials (RCTs) that assessed reconstructive surgery in the treatment of pressure ulcers.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected the studies, extracted study data, assessed the risk of bias and undertook GRADE assessments. We would have involved a third review author in case of disagreement.
MAIN RESULTS
We identified one RCT conducted in a hospital setting in the USA. It enrolled 20 participants aged between 20 and 70 years with stage IV ischial or sacral pressure ulcers (involving full-thickness skin and tissue loss). The study compared two reconstructive techniques for stage IV pressure ulcers: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialised and deeply inset to obliterate dead space. There were no clear data for any of our outcomes, although we extracted some information on complete wound healing, wound dehiscence, pressure ulcer recurrence and wound infection. We graded the evidence for these outcomes as very low-certainty. The study provided no data for any other outcomes.
AUTHORS' CONCLUSIONS
Currently there is very little randomised evidence on the role of reconstructive surgery in pressure ulcer management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.
Topics: Adult; Aged; Debridement; Humans; Middle Aged; Pressure Ulcer; Plastic Surgery Procedures; Wound Healing; Young Adult
PubMed: 36228111
DOI: 10.1002/14651858.CD012032.pub3 -
International Journal of Nursing Studies Oct 2023Pressure ulcers are a major health concern. They have a significant impact on the healthcare system and individuals, reducing quality of life across several domains. In... (Review)
Review
BACKGROUND
Pressure ulcers are a major health concern. They have a significant impact on the healthcare system and individuals, reducing quality of life across several domains. In community settings, self-management behaviours are central to their prevention. However, adherence with pressure ulcer prevention guidelines remains low, with little evidence guiding the relationship between patients and healthcare professionals to establish a concordant partnership.
OBJECTIVE
To synthesise evidence on factors contributing to community-based pressure ulcer prevention using the Theoretical Domains Framework and the Capability, Opportunity, Motivation, Behaviour (COM-B) model of behaviour.
DESIGN
Mixed methods systematic review and narrative synthesis.
METHOD
Systematic searches were conducted in the CINAHL, Cochrane, EMBASE, PsycINFO, PubMed, Scopus, and Web of Science databases on 14th December 2022. Studies were eligible if they contained data on the factors associated with adherence and concordance with pressure ulcer prevention guidelines in the community for patients, caregivers, and healthcare professionals. Methodological quality was assessed using the Hawker tool. Findings were synthesised using the Theoretical Domains Framework. The resulting themes were mapped onto the Capability, Opportunity, Motivation, Behaviour (COM-B) model.
RESULTS
Thirty studies were included in the review, including quantitative, qualitative, and mixed methods research. The synthesis identified 12 of the 14 Theoretical Domains Framework domains, with knowledge, social influences, beliefs about consequences, and beliefs about capabilities the most prevalent. Although knowledge appears to be an important contributor to adherence with prevention guidelines, knowledge alone does not appear sufficient to achieve concordance. A concordant relationship was facilitated by healthcare professionals' knowledge, motivation to work alongside patients and their priorities, and interpersonal skills to build rapport and trust, whilst barriers included lack of healthcare professional skills to navigate sensitive issues, paternalistic views of patient compliance and organisational processes that impact building rapport.
CONCLUSIONS
Several psychosocial factors may affect the ability to achieve concordance between individuals, caregivers and healthcare professionals with pressure ulcer prevention guidelines in the community. However, data regarding the efficacy of behaviour change interventions targeting these constructs is limited, with further research required to guide intervention development in this area.
Topics: Humans; Pressure Ulcer; Quality of Life; Motivation; Health Personnel; Patient Compliance; Qualitative Research
PubMed: 37542960
DOI: 10.1016/j.ijnurstu.2023.104561 -
International Journal of Nursing Studies Dec 2014Pressure ulcers are considered to be an adverse outcome of care that should never occur in clinical practice. The formation of a pressure ulcer is also perceived to be... (Review)
Review
BACKGROUND
Pressure ulcers are considered to be an adverse outcome of care that should never occur in clinical practice. The formation of a pressure ulcer is also perceived to be an indicator of poor quality nursing care. Therefore, pressure ulcer prevention is a priority for nurses, healthcare professionals and healthcare organisations throughout the world. A key factor in pressure ulcer prevention and management is individual nurse decision making.
OBJECTIVES
To synthesise the literature on the judgement and decision making of nurses in relation to the assessment, prevention, grading and management of pressure ulcers in all care settings (hospital and community).
DESIGN
A systematic search of published literature relating to judgement and decision making in nurses, with a focus on the prevention and management of pressure ulcers.
METHODS
A search of electronic databases from 1992 to present, together with hand searching of the reference lists of retrieved publications, to identify published papers that reported results of studies evaluating the decision making of nurses in relation to the prevention and management of pressure ulcers. Abstracts were independently reviewed by two authors and full text of potentially relevant articles retrieved. Each paper included in this systematic review was evaluated using recognised appraisal criteria relevant to the specific study design. Included papers provided empirical data on key aspects of nurses' pressure ulcer related judgements and decision making. Data were synthesised into themes using narrative analysis.
RESULTS
Sixteen studies and one systematic review were included in the review, focusing on pressure ulcer risk assessment, pressure ulcer prevention, grading of pressure ulcers and treatment decisions. The results indicated that assessment tools were not routinely used to identify pressure ulcer risk, and that nurses rely on their own knowledge and experience rather than research evidence to decide what skin care to deliver.
CONCLUSIONS
Emphasising pressure ulcer risk assessment and pressure ulcer grading in clinical practice is unlikely to deliver improved outcomes. Further research into nurses' pressure ulcer related judgements and decision making is needed and clinicians must focus on the consistent delivery of high quality care to prevent and mange pressure ulcers to all patients in clinical practice.
Topics: Humans; Nursing Staff; Pressure Ulcer
PubMed: 24835078
DOI: 10.1016/j.ijnurstu.2014.04.009 -
Journal of Tissue Viability Aug 2023To systematically synthesize research evidence on barriers and facilitators to pressure injury prevention in hospital settings. (Review)
Review
OBJECTIVE
To systematically synthesize research evidence on barriers and facilitators to pressure injury prevention in hospital settings.
METHODS
A systematic literature review of quantitative, qualitative, and mixed methods research was undertaken using PubMed, MEDLINE, Embase, CINAHL, and Cochrane Library. Studies that reported barriers or/and facilitators to pressure injury prevention in the acute care settings and published in English from 2008 to 2022 were included. Studies were excluded if they were conducted in residential care facilities and nursing homes, or other long-term community care settings. Two authors independently screened articles against the inclusion and exclusion criteria. Quality appraisal was conducted by two authors by using the Mixed Methods Appraisal Tool. Reported results were mapped to the Theoretical Domains Framework to identify the barriers and facilitators to pressure injury prevention.
RESULTS
A total of 78 studies were included. There were 65 quantitative studies, 11 qualitative studies, and two mix-methods studies. The most salient Theoretical Domains Framework domains identified in this review were "Knowledge", "Skills", "Environmental Context and Resources", "Optimism", "Social/Professional Role and Identity", and "Social influences".
CONCLUSION
The barriers and facilitators to pressure injury prevention in hospital settings identified in this systematic review were diverse, and included issues at both individual and organizational level. Healthcare organizations can address the barriers and facilitators from the influential Theoretical Domains Framework domains. Future research is required to investigate the effectiveness of behaviour change interventions that specifically target these barriers and facilitators to pressure injury prevention.
Topics: Humans; Pressure Ulcer; Nursing Homes; Hospitals; Crush Injuries; Qualitative Research
PubMed: 37150650
DOI: 10.1016/j.jtv.2023.04.009 -
International Wound Journal Oct 2023This systematic review aimed to examine the knowledge of caregivers regarding pressure ulcer (PU) prevention. A thorough, methodical search was conducted from the... (Review)
Review
This systematic review aimed to examine the knowledge of caregivers regarding pressure ulcer (PU) prevention. A thorough, methodical search was conducted from the earliest date to February 1, 2023 using keywords extracted from Medical Subject Headings such as "Caregivers", "Knowledge", and "Pressure ulcer" in various international electronic databases such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex and Scientific Information Database. The quality of the studies included in this systematic review was evaluated using an appraisal tool for cross-sectional studies (AXIS tool). In total, 927 caregivers participated in the eight studies. The average age of the participants was 40.50 (SD = 12.67). Among the participants, 61.87% were women. The average caregiver's knowledge of PU prevention was 53.70 (SD = 14.09) out of 100, which suggests a moderate level of knowledge. Factors such as level of education, age, occupation, information about PUs, attitude, and practice had a significant positive relationship with caregivers' knowledge related to the prevention of PUs. Knowledge had a significantly negative relationship with age. In addition, marital status, type of relationship, age, gender, occupation, level of education, and inpatient wards had a significant relationship with caregivers' knowledge regarding PUs prevention. Therefore, managers and policymakers in the medical field can help increase caregivers' knowledge by providing an online or in-person educational platform relevant to PU prevention.
Topics: Humans; Female; Male; Caregivers; Cross-Sectional Studies; Ulcer; Pressure Ulcer; Suppuration
PubMed: 36960763
DOI: 10.1111/iwj.14168