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Biz Morrissey PICO Question!

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Elizabeth Morrissey

on 22 April 2014

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Transcript of Biz Morrissey PICO Question!

Biz's PICO Question!
PICO QUESTION
In patients with wounds, is there a more effective advantages for tissue formation (healing) using a closed negative pressure system versus other wound healing methods?
A Prospective randomized controlled trial comparing negative pressure dressings and conventional dressings methods on split-thickness skin grafts in burn patients
Purpose: to determine if NPD improves graft takes as compared to conventional dressings in burn patients
Independent Variable:Successful graft take
Dependent Variable: NPD and conventional dressings
Design: Randomized control study
Sample
Number: 40 split-skin grafts on 30 patients
Age: 7-60 yrs (32)
Diagnosis: Burns
Other: Health status of a patient who would benefit from a skin graft
Setting: Tertiary hospital with a special burn unit
Tools: Vasaline gauze, cotton pads, elastic bandages, low density polyurethane foam (1&1/2 inch) flexiable transparent tube of 5 mm and innder diamater of 1 m length, wall suction
High Bacterial Load in Negative Pressure Wund Therapy (NPWT) foams used in treatment of chronic wounds
Purpose: Investigate the bacterial load and micro-biological dynamics in NPWT foam removed from chronic wounds
Independent Variable: Foam in chronic wounds
Dependent Variable: Bacterial Load and microbiological dynamics
Design: Experimental
Sample:
68 foams from 17 patients
Jan2010-Dec2011
greater than 18 (63)
Health Status: Chronic wounds (>3 months) recieving NPWT (VAC)
Consecutively hospitalized ambulatory patients
Setting: specialized setting for paraplegia and craniocerebral injury
Major Tools: Foam, sterile air tight container, Ringers solution

Negative Pressure Wound Dressings, Whats the BIG DEAL?
V.A.C.® Therapy System has revolutionized the way in which caregivers treat the most serious, complex wounds. V.A.C. Therapy utilizes an open-cell polymer foam dressing that is conformed to the wound bed. When sealed and placed under negative (vacuum) pressure, the system creates a unique wound healing environment that has been shown to promote the wound healing process, reduce edema, prepare the wound bed for closure, promote the formation of granulation tissue and remove infectious materials.
NSG 276 Elizabeth Morrissey Amy Sparks April 2014
Implement of change
There needs to be an evaluation of every skin lesion to see if NPWT may be a viable option and if the benefit of pathogen binding mesh can be used over foam if pain is a problem. This could be done using a scale with numerical values assigned.

Nurses can implement non therapeutic options for pain reduction

Doctors and surgeons will be the ones who need to evaluate if the patient would benefit from using a NPWT than that of the accepted therapy being practiced.

Since the benefits of a shorter wound healing, having a adhesive dressing protect the wound from environmental contamination, and a greater graft success rate, doctors need to be educated and use a NPWT when available, and certified to evluate the use of NPWT in patients. Could be accomplished by attending a seminar or taking a certification online

The wound care nurse could also educate patients who might benefit from NPWT about NPWT and the benefits of it.
Evaluation
I would evaluate these recommendations by seeing how many doctors chose to use a NPWT device over other methods to heal wounds. Since NPWT is already accepted into practice, and being used now, it would be easy to evaluate by going to a wound clinic and seeing out of a certain amount of wounds being treated, how many that were able to be closed using a NWPT and what it was actually treated with.

A way to measure if the pathogen-binding mesh is reducing the pain over the foam would be to have the patient who have the foam rate their pain before and after dressing changes, then switch them to the pathogen binding mesh and evaluate their pain again. It could also be done by just comparing the average pain levels of patients using the mesh verses the foam.

A way to make sure that doctors considered NPWT would be to make it a requirement for them to state it in their notes wether or not a NPWT treatment option was discussed and viable for treatment fo wound.
Findings!
21- NPD
19- Conventional
A Mann-Whitney test showed that there were no significant difference in area of the grafted wounds between the two gorups
Additional cost for NPD was only $9.95
Graft taking in NPD ranged from 90-100% while the conventional group ranged between 70-100%
NPD averaged 8 days of dressing while conventional dressings averaged 11 days

Paired t-test showed that the difference in outcomes were statistically significant with p< 0.001

NPD improve graft takes in burn patients and can partially be considered when wound bed and grafting conditions seem less than ideal. NPD is also effectively assembled using locally available materials thus significantly reducing the cost of treatment.

Rating: well-designed controlled study without randomization
Feasibility: very feasible (cost, less dayd spent healing)
Benefits/ Risk? ABSOLUTLY!

Limitations: assessment could be blinded in study owing to the large apparatus needed to apply suction- a problem that many authors studying NPS and VAC treatment run into. Observer Bias
Findings!

All NPWT foams are colonized by high numbers of bacteria, and the bacteria load remains persistantly high despie routinely changing the foam, on average, every 3 days.
Changing foam in some patients introduced new bacteria
PU foam with higher negative pressure has less baceria thena negative presure using PVA foam and a lower pressure.
49 were were PU foam while 8 were PVa foam
Foam originated from NPWT system using 125 mmHg pressure had significantly lower log of highest concentration of bacterial load

Limitations:
Did not perform quantitative tissue cultures in the surrounding of NPWT in parellel (did the patient alreayd have that bacterium??)
do not have complete data possible cofunding ariables, such as wound size, number of prior sugeries, and insertion depth of the foam
The observation that PU foam led to lower bacterial load than PVa foam should be interpereted cautiously as the numbers of PVA are low compared w/ the number of PU foam

Study offered options to reduce the bacterial load to promotoe wound healing:
change foam more frequently than normal (3 days)
using antiseptic or antimicrobial in foam

Rating: One randomized controled trial
Benefit: Maybe?
Feasibility: Absolutly


Negative-pressure wound dressings to secure split-thickenss skin grafts in the perineum
Purpose: to evaluate the effects of NPWD on split-thickness skin grafts in the perineum by comparing would healing rate and complication rate and complication rate with that over conventional tie over dressings
Independent Variables: Wound healing and complication rate
Dependent Variables: NPWD and Tie over dressings
Design: Experimental
Sample:
26 patients (14 NPWD, 12 tie-over dressings)
56.6 mean age
25 male, 1 female
15 hx of smoking, 8 DM (4 NPWD)
Mean wound size: 273.1 cm2
Setting: Acute care hospital
Tools: VAC, sponge, petroleum gauze, gauze wool, heavy cotton gauze
Findings!
No statistical findings significant between the patients having smoking or DM history. Also no significant between size of wound, mechanism of defect and wound depth.
96.2% survival rate in skin graft with NPWD
90.4% survival rate in skin graft with tie-over dressing
Average days of healing for NPWD was 15.5 days and tie-over dressings was 20.2
NPWD had significantly higher graft survival rate P=0.036 and shorter recovery rate p=0.01 than the tie- over dressings
Limitations: not perspective, randomized or blinded! Not all factors that can have an effect on the graft healing are not included in this study die to difficulty to create a standardization. Also a small study size.
Rating: one well-designed controlled study without randomization
Feasibility: yes!
Benefit / Risk? Absolutely!
Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds
Purpose: to help find a way to reduce the one negative aspect of using NPWD which is pain during dressing changes and odor.
Inpendent variable: Wound treatment with Gauze based NPWD
Dependent: Pain and odor
Sample:
152 patients, 53-chronic wounds, 78 acute wounds
mean age 58
56% male
comorbidities included DM, hypertention
mean duration of NPWT 18 days
Setting: mix: 95% hospital setting, 31 patients home Setting, 23 outpatient wound clinics, and 3 in long term care facilities
Major Tools: EZ-care device, VISTA, saline moistned anti-microbial gauze
* this part of the study addresses the secondary objectives in study which is wound pain and odor, not the par tof the study that looked at granulation tissue formation, exudate management reduction in would dimensions.
Findings!
wound pain and odor were significantly reduced P< 0.001 over wound therapy
80% experienced no pain during dressing changes, and 96% experienced no damage to the wound beds on removal
79% were considered easy dressing changes
20 minutes on averag was the time to complete the dressing changes
11 out of 854 were considered uncomfortable changes
98 patients (64%) had no odor at beginning and 126 (84%) had no odor at the end of therapy. 41 (27%) patients saw a reduction in odor fom beginning t end. 98 had no change (65%) and 11 (7%) had an increase in odor from the beginning of therapy to the end.
610 changes only required one nurse, 195 required 2 and 1 required 4 nurses.

Limitations: High dropout rate of study and exclusion of members. Not very realistic....
Feasibility? YES
Benefit / Risk- absolutly!!
Use of bacteria and Fungus-binding mesh in negative pressure wound therapy provides Significant granulation tissue without tissue ingrowth
Purpose:to compare pathogen-binding mesh, black foam, and gauze in NPWT with regard to granulation tissue formation and in growth of wound bed tissue in the wound filter
Independent Variable: granulation tissue formation, ingrowth of wound bed tissue
Dependent Variable: pathogen binding mesh, black foam, gauze
Sample: 8 PIGS!
Setting: animal clinic
Design: experimental
Tools:
pathogen binding mesh, foam, gauze, animals
Findings: Pathogen binding mesh produced more granulation tissue, leukocyte infiltration, and tissue disorganization in the wound bed then gauze, but less than black foam.
All 3 wound filters cause microderformation of the wound bed surface. Little force was used to remove the pathogen binding mesh and gauze while the foam required a significant amount of force
The wound bed tissue grew into foam but not into pathogen binding mesh or gauze,

Limitations: PIGS! no reduction of bacteria being used in pigs (downside)
Feasible: yes!
Risk/ benifit? MAYBE
Recommendations for practice based on evidence
the use of 125 mmHG of negative suction- increases leukocytes to surface, granulation tissue and wound healing at a faster rate.
Using pathogen-binding mesh instead of foam in cases where pain is higher than a 5 out of 10 on a numeric scale
Changing foam every other day instead of every three days- cut down on in growth of tissue into foam, reduce amount of bacteria on foam
Provide non-therapeutic approaches to pain before wound dressing change- help reduce the amount of pain
Using NWPT in cases of skin grafting where other conventional dressings may be used- Cost is relatively low, survival of graft is more successful and length of wound healing is shorted
Using NPWT in cases where skin integrity has been compromised o the subcutaneous layer or muscle layer.
Do not use a regular gauze dressing in woun of patients who are incontinent- leads to easy contimanation
On a side note
: in this study, on patient was incontinent and soiled her dressing change introducing E. coli into her wound. Due to this, she experienced a 33 day wound healing process and some of her skin graft was rejected. Researchers note that this could have been prevented if they were using the adhesive skin barrier in the NPWT
Synthesis
After reviewing these articles it is easy to see that there are many benefits to using a NPWT over conventional dressings when dealing with wounds. It is important to also look at it in regards to skin grafts to make sure optimal tissue formation is achieved. When dealing with the two reoccurring downsides of NPWT (pain and odor) some non pharmacological methods may be influential along with choosing a different matrix like mesh, gauze or foam between the wound and suction
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