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Pressure Area Care
Complete a 3000 word literature review surrounding current and historical nursing practices in pressure area care in order to demonstrate the use of evidence-based practice.
Introduction
The healthcare professions have had to deal with pressure sores from before recorded time. We can find pressure sores on the mummies of Egyptian noblemen which are more than 5,000 years old. (Thomson-Rowling J 1961)They are still with us today. A study from over two decade ago quoted findings of pressure sores on 29% of hospital inpatients, 33% of ITU patients and 66% of elderly patients with fractured hip pathology and at the time of death 24% of the population have them (all figures relate to stage 2 or greater pressure sores) (Eckman KL. Decubitus 1989;2:36-40).
Historically, the nursing profession has based its activities and procedures on a traditional base and not within a framework of scientific verifications (Roper N 1977) Three decades ago, writers were calling for nursing to be a research based profession and lamenting the fact that there was a marked lack of research evidence underpinning the routine practice of nursing (Gortner SR 1976).
It is fair to comment that the last three decades has seen a marked change in this state with the progressive advent and emergence of evidence based practice to the point that it is currently considered to be the basis of the majority of professional nursing care. (Yura H et al 1998). There are a number of important factors and considerations that underlie this statement. Hunt's well publicised plea to the profession that "each nurse must care enough about her own practiceto want to make sure it is based on the best possible information" (Hunt J 1981) was met with both enthusiasm and a realisation of the barriers that stood in its way. They included ( and still include) time constraints, limited access to the literature, a lack of training in critical skills of appraisal and, most fundamentally, a professional ethos and ideology that placed a great emphasis on the practical rather than the intellectual component of knowledge together with a work environment that did not actively encourage the seeking out, researching and recording of new information (after Royle J et al 1996).
Critics of evidence based practice have suggested that it promotes the concept of a cookbook of practices that have to be dogmatically followed. (Haynes RB et al. 1996). An arguably more enlightened view would suggest that professional training includes learning the basic pathophysiology and anatomy and acquiring experience. It is the effective application of this experience that requires a sound evidence base. Research evidence can aid the professional decision making process, but cannot either do the clinical examination or collate the vast amount of snippets of information that pass between patient and nurse. It is this clinical expertise that is the crucial element that separates evidence based nursing from the cook book approach with its mindless application of both guidelines and rules (White S 1997).
Literature Review
Although the bulk of this review is to be on pressure sore treatment, there is a clear emphasis on the importance of the evidence base in treatment. We shall therefore begin this review with a comment relating to the analysis of the role of the nurse in evidence based research as perceived by Pearson. (Pearson A 2000). This article is an exemplary tour de force of the arguments both for and against the need for an evidence base in nursing and the research that underpins it. Pearson points to the division between lay nursing and professional nursing which is demarcated by the application of research based practices. It traces the watershed of management provided by Nightingale's reforms through to the 70s and 80s where theoretical constructs of practice began to evolve and be adopted, through to the current evolution of the nurse specialist and nurse practitioner whose professional status is centrally evidence based.
To consider the evolution of the evidence based review in the area of pressure sores we should perhaps begin with a historical note of scientific interest. Sir James Paget is recorded in 1862 as making the comment that
Elderly patients with femoral neck fractures and other high riskgroups develop them (pressure sores) early, "chiefly in the first week," and then made the observation They often appear on the day of operation. It is not just the patient, but every part of his or her body,that must survive the operation.(Bliss MR 1992).
Here we have a classic example of a clinical comment which may, of course, be absolutely true, but has no evidence base whatsoever other than the author's own opinion. It may be completely biased and have no basis in statistically provable fact. It clearly won't have been subjected to the scrutiny of a randomised controlled trial but will have doubtless been accepted without question by countless numbers of healthcare professionals over the years.
Having outlined the central importance of the evidence base in this review we shall make a rather more contemporary analysis with the Vohra paper (Vhora RK et al 1986). The paper is now 20 years old and, in many ways is a paper which exemplifies the thrust of this review. It is, in itself, an excellent and comprehensive overview of the pathophysiology, aetiology and management of the pressure sore. The paper appears to be very authoritative and cites nearly 70 references, and yet its value as a suitable evidence base is severely restricted. (MacLean DS 2003).
A critical analysis of the references quoted show that very few of these references are actually study based (as opposed to opinion based), and only one of these is a properly constructed randomised controlled trial which has proper statistical analysis and minimal possibilities for bias. It is fair to say that the paper does present many comparative studies which examine the efficacy of one treatment against another. This may be of some practical value if a nurse is on a ward that only has the two types of equipment cited but, as a general overview, we need to be able to cite evidence that one particular type or modality of treatment is superior to all others for a particular category of pressure sore and that we can point to unbiased, scientifically derived evidence to support that view.
To illustrate this point, it is clearly of minimal value to a patient to be able to say to them that a comparison of rubbing a pressure sore with honey has been found more beneficial than rubbing it with butter when the use of a ripple mattress is clearly superior to both of them.
It is certainly fair to say that the authors clearly appreciate the shortcomings of their own paper as they conclude with the comment:
Carefully conducted clinicaltrials are urgently needed to evaluate which products shouldbe used in this all too common and very debilitating condition.. In the absence of carefully conducted clinical studies,the benefit of a variety of available medical treatments isdoubtful.
At the time that this paper was written (20 years ago), the comment was certainly true. We can illustrate the evolution and historical perspective on the treatment of pressure sores with the observation that the sum total of the principles of treatment of pressure sores was summed up by the authors in the headings:
Improvement in general health and nutrition
Restoration of tissue perfusion by relief of pressure
Maintaining a clean wound
Preventing or treating infection
Stimulation of granulation tissue
Arterial reconstruction where necessary.
If we move nearer to the present day and examine a rather more recent paper we could turn to Bliss (et al 1999). This is also an overview of the area of pressure sores presented as an editorial. We should also note that one of the authors is a nurse. The tone of the paper is set by the opening comment:
Pressure sores are often thought to be slothful chronic wounds forming slowly because of poor nursing
Which is a quote from another peer reviewed nursing journal (Dealey C 1992).
The fact of the matter is that we are not left in a position to assess the validity of this comment, simply because yet again it is quoting opinion rather than firm, scientifically evaluated evidence. There is, however, a significant difference between this paper and the one we cited from the preceding decade, and that reflects the quality of the references cited. This paper cites only 12 references, and in this instance, over half quote peer reviewed randomised controlled trials as their source. This clearly represents a change in both presentation and ethos. We would suggest that such changes are not simply a chance finding in two random papers, but that they do represent a genuine change in the style, and indeed expectation, in the way that papers are, not only written, but also accepted for publication in the major professional journals.
The paper itself provides us with a very useful overview of the pathophysiology of the condition together with the evidence base which underpins many of the treatments that are currently (in 1999) used. It points to avoidable factors such as lying on A&E trolleys for long periods of time, dehydration and lack of analgesia which may inhibit movement as all being contributory causes. Importantly, it cites the trials on which it bases these comments and the appropriate recommendations that go with them. Interestingly, it makes comment on the possibility of the interaction of intraoperative procedures, medications and anaesthetics as being hitherto unrecognised contributory factors and calls for more research into their role in the aetiology of the condition.
It closes by citing a classic randomised controlled trial (Gebhardt KS et al 1994), which contrasted two groups of patient, those who were nursed in bed and those who had bed rest indispersed with spells of sitting in a chair and the relative differences in the two groups in relation to pressure sores.
In many respects, the Gebhardt trial is a reflection of both the calls noted in the previous paper for proper scientific scrutiny to be brought to bear on the subject and the evolution of the expectation of the healthcare professions into the requirement for a firm evidence base for their continued work. (Morris A 2002)
This move towards evidence based nursing practice was exemplified by the development of the Waterlow Scale (PN 1991), which was based on a recognition of the need for a standardised assessment tool that could be used as a comparative base for controlled trials. It is now (arguably) the most commonly used assessment tool in this field. (Hogston, R et al.2002). Nurses can utilise this scale to predict the degree of risk attached to each individual patient and to select the most appropriate treatment modality, based, not on opinion or experience, but on a properly evaluated and scientifically tested plan which has been unequivocally shown to provide positive benefit (NT 1996).
We can move on from this point to the evolution of new assessment tools which have been evaluated against the more modern methods of treatment. More sophistication can be seen in the paper by Gardener S (et al 2005) which considers the application of a new pressure sore assessment scale which is designed to predict the likelihood of a given pressure sores healing -(PUSH).
This study is a fully randomised controlled trial which is prospective in construction. This study can be viewed as the logical progression from the pathway which started with the Egyptian mummies, via Sir James Paget, through the representative papers that we have reviewed, to the expression of modern-day treatment practices. It takes a clinically defined situation, proposes a solution and then prospectively tests that solution in a randomly controlled setting, which is experimenter blinded, and is able to make the virtually unchallengable statement:
The PUSH tool provides a valid measure of pressure ulcerhealing over time and accurately differentiates a healing froma non-healing ulcer. It is a clinically practical, evidence-basedtool for tracking changes in pressure ulcer status when appliedat weekly intervals.
We would suggest that this is a fundamentally different approach to that which was commonplace even two decades ago.
Conclusion
This review has been concerned, not so much with the actual treatment of pressure sores, but has used the pressure sore as a vehicle to examine the evolution of the evidence base that now underpins the modern professional practice, not only of nursing, but of virtually all of the healthcare professions. (Deave T 2005)
To a large extent this review also illustrates the need for a fully critical review of the evidence presented. It is a recognised trap for the inexperienced, or perhaps unwary reader, to simply read a paper and uncritically accept the conclusions set out at the end, as being worthy of adoption simply because they appear in print. (Cochran & Cox. 1957).
It is, of course, a matter of commonly accepted observation, that the current trend amongst editors of the reputable peer reviewed professional journals, is for progressively greater degrees of independent scrutiny, scientific validity and the open acknowledgement of potential sources of bias in their published work. This effectively translates into a greater confidence in the fact that printed and published results and conclusions can be effectively assimilated into a professional evidence base. (Mohammed, D et al 2003)
Such comments should not, however, be regarded as absolute. We have presented and cited examples of papers which have quoted other evidence form other contemporary papers and, to the unwary reader, they appear to be perfectly respectable. On closer scrutiny however, one can ascertain that the sources quoted are not capable of providing a sound evidence base for the resultant paper as they include demonstrable sources of bias. The natural corollary to this argument is that these areas of weakness clearly undermine the value of the overall results presented in the paper itself.
It is perhaps the advent of the pressure sore scoring scales that have proved to be the single most useful tool in the quest for a firm evidence base as this has allowed the construction of various meta-analyses of treatment outcomes. In the past the usefulness of the meta-analysis tool has been severely hampered by the inability to accurately compare similar trials because of their differences in either measuring or diagnostic criteria. This means that the possibility of bias has been comparatively great and the outcome value significantly reduced. With common measurement criteria the overall value of the investigation is proportionately enhanced and has a greater validity because of it. (Morton V et al 2003),
We believe that these observations will assist in the critical analysis of papers in this area.
References
Bliss MR. 1992
Acute pressure area care: Sir James Paget's legacy.
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Bliss M and Bruno Simini 1999 When are the seeds of postoperative pressure sores sown? BMJ, Oct 1999; 319: 863 - 864
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Pressure sores: the result of bad nursing?
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Eckman KL. 1989
National Funeral Directors Association (NFDA) study
Decubitus 1989;2:36-40).
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