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 Incontinence Nutrition What surfaces and when?

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

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

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

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

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?

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?

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

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.

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.

Other idiosyncrasies

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

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

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?

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

Individual studies Type of study important Require own quality check 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)

Conclusion 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