PICO By: Victoria A. Volway Hi, I’m Victoria Volway speaking for my PICO Presentation for COHP 450.

Introduction PICO Question: In patients with diabetic foot ulcers, does negative pressure wound therapy, compared to standard moist wound care, lead to improved healing? Population: patients with diabetic foot ulcers Intervention: negative pressure wound therapy Comparison: standard moist wound therapy Outcome: improved healing So what is PICO? PICO is a way to format research questions asked in Evidence Based Medicine. For my PICO question…..

Results of Literature PubMed, Nursing Central Keywords searched: diabetic foot ulcers, negative pressure, wound care, healing Results of search: There were many peer-reviewed studies found on PubMed. I used my Nursing Central app to learn more about negative pressure wound therapy. Articles published within last 7 years-current

Results of Literature [CITATION NEEDED] Blume, P. A., Walters, J., Payne, W., Ayala, J., & Lantis, J. (2007, December 27). Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers [Electronic version]. Diabetes Care, 31(4), 631-636. doi:10.2337/dc07-2196 Nain, P. S., Uppal, S. K., Garg, R., Bajaj, K., & Garg, S. (2011, June). Role of negative pressure wound therapy in healing of diabetic foot ulcers. Journal of Surgical Technique & Case Report, 3(1), 17-22. doi:10.4103/2006-8808.78466 Two articles that I found helped answer my PICO question are:

Results of Literature Why did I choose these articles? Article 1: Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers Article 2: Role of negative pressure wound therapy in healing of diabetic foot ulcers.  Both of these articles compared NPWT to SMWT (also referred to AMWT in Article 1)

Negative Pressure Wound Therapy (NPWT) is a newer noninvasive adjunctive therapy system that uses controlled negative pressure using Vacuum-Assisted Closure device (VAC) to help promote wound healing by removing fluid from open wounds through a sealed dressing and tubing which is connected to a collection container. The use of sub-atmospheric pressure dressings, available commercially as a VAC device, has been shown to be an effective way to accelerate healing of various wounds. Promote the wound healing process, reduce edema, prepare the wound bed for closure, promote the formation of granulation tissue and remove infectious materials.

Findings-Article #1 Comparison of negative pressure wound therapy using vacuum- assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers Theory Type of study/design: Multicenter randomized Control Study Methods: 335 after exclusions Findings: NPWT >SMWT; 60.8% compared to 40.0% achieved ulcer closure without other interventions (i.e. sx) There was no stated theory or hypotheses, as the study was comparing the two methods of treatment to determine the safety and efficacy of NPWT compared to standard moist therapy. This study was a multicenter randomized control trial which means…It included 342 patents from 37 different diabetic foot and wound clinics with diabetic foot ulcers, measuring >2cm after debridement. Participants with ulcers that could be caused for other reasons, such as osteomyelitis, cellulitis, or poor perfusion of the extremities, were excluded from the study. This helps to diminish possible uncontrolled variables . They randomly selected some patients to receive NPWT and other, SMWT. Patients were examined weekly for the first 4 weeks (day 28) then every other week until day 112 or until complete ulcer closure. www.randomizer.org

Findings-Article #2 Role of negative pressure wound therapy in healing of diabetic foot ulcers.  Theory: NPWT? Type of study/design: Experimental Methods: 30 patients; study group and control group Findings: Those in Group A (NPWT) healed faster with 60%, compared to 20%, being healed by the first week. The researchers suspect that NPWT may prove to be more beneficial, best treatment for ulcerations is ill-defined. The present study was done on 30 patients at Dayanand Medical College and Hospital, Ludhiana. Patients were randomly divided into two groups - study group and control group. Methods were similar to the previous article in that patients were placed randomly and monitored regularly to evaluate level of healing based on appearance of granulation tissue and wound size. Negative Pressure Wound Therapy (NPWT) is a newer noninvasive adjunctive therapy system that uses controlled negative pressure using Vacuum-Assisted Closure device (VAC) to help promote wound healing by removing fluid from open wounds through a sealed dressing and tubing which is connected to a collection container. The use of sub-atmospheric pressure dressings, available commercially as a VAC device, has been shown to be an effective way to accelerate healing of various wounds.

Ethical Considerations Article 1: Safe trial, voluntary informed consent Article 2: informed consent Article 1: Researchers conducted the trial safely, providing for alternative therapies if the ones they were receiving were not helping (i.e. sx, off-loading therapy); all participants gave voluntary informed consent and received post base-line treatment Article 2: Did not discuss as many safety measures, but obtained informed consent, taking priority that the patients understood what would be happening.

Strengths Article 1: multicenter randomized trial Article2: support from other studies Article 1: “The benefits of multicenter trials include a larger number of participants, different geographic locations, the possibility of inclusion of a wider range of population groups, and the ability to compare results among centers, all of which increase the generalizability of the study” No significant demographic data differences that would hinder results, Article 2: Showed support from other studied performed Weakness?: EBP=we still use standard moist saline dressing changes, may be time to update

Quality of Studies Article 1: detailed and very in depth; few limitations Article 2: not as detailed, but a reliable study. May have limitations. Both articles have qualified authors, showing no bias on the outcome, and are easily read. May have limitations in that it was only performed on 30 participants and did not include a lot of detail

Credibility Both articles are published from accredited journals Article 1: Authors come from reputable universities throughout the US. Article 2: Medical Centers in India

Can we Incorporate? Communication/Implementation: Administration/managers  nurse educators  nurses and other HCP’s Potential: High potential! Any barriers? Communicated to hospital staff and managers, then implement policies and have nurse educators, and other health care professionals, train in NPWT (Negative pressure wound therapy) Very high potential to change. NPWT is very cost effective, similar to AMWT (advanced moist wound therapy), and if healing time is shortened, less supplied would be used resulting in lower cost and a better outcome for the patient. One study showed that NPWT was related to fewer re-amputations. Which saves more money in the long run and more time and hardship on the patient. Any barriers?

Additional PICO Questions? In patients with diabetic foot ulcers, does age play a role in efficacy of healing, when undergoing negative pressure wound therapy? For hospitals/clinics with patients with foot ulcers, why isn’t NPWT the standard, as opposed to standard saline wound therapy? Another question I would ask is why aren’t we implementing?

Conclusion Negative Pressure Wound Therapy proves to have higher efficacy in would healing r/t time and level of healing.