Best evidence: the changing practices of wound care

For practitioners of the past, evidence-based medicine (EBM) meant something very different to what it is today. Back then, a senior colleague would offer advice and practitioners would carry out the task with those words of wisdom ringing in their ears. This would be the case until they were confident enough or of a seniority that allowed them to practise in a way that they felt comfortable.

However, even when the practitioners had reached a level at which they could impart their own advice, much of what they did was based on their own experience and that of their senior colleagues. In recent years, EBM has been changing and challenging the understanding of patient care. Although based on a philosophy rooted in the 1800s, its impact continues to gain traction, particularly in wound care.

Andrew Tunnicliffe: Can you tell us how wound-care practices came about and how history has helped shape the wound treatment of today?

Terry Treadwell: Things have changed a lot in wound care recently. In the last ten-15 years, we have come to learn more about the science of the healing wound. It is amazing how much information we have garnered about them and how they heal. With that information has come a variety of new approaches to wound treatment.

Different kinds of bandages and dressings have appeared on the market, all of which claim to heal a variety of wounds. We have come from the days of using gauze dressings to more exotic items like cell-containing products or tissue-engineered skin products. We also have Matrix products and dressings that maintain a moist wound environment, and gene therapy is being discussed and actively pursued.

One of the basics that has changed includes the approach to moist wound healing. Historically, the practice was to let a wound dry out, thinking it would heal if it was kept dry. In 1963, Dr George Winter and others found this was not the case and that wounds kept in a moist environment heal faster with less pain, less scarring and with fewer infections. However, many in the healthcare community have been very slow to adapt this approach.

Another approach to wound care that has slowly developed over the past 15 years has been that of the multidisciplinary wound team.

How has the introduction of a multidisciplinary approach helped further wound-care management practices?

This multidisciplinary approach has been necessary because of our better understanding of the pathology and physiology of wounds. The healing of wounds can be very complex and involve multiple body systems, all of which influence the wound-healing process. If wounds are to heal appropriately, all of these multiple co-morbidities need to be controlled.

A multispeciality group can bring many different approaches to the table, which are essential in managing all of the many co-morbidities that are present in our patients and their treatment. This team approach brings a particular knowledge base to wound care, strengthening the entire team by filling any knowledge gaps. Evidence has even shown that if multidisciplinary groups are involved in treating wounds, healing rates are significantly better than if patients are treated in private clinics without a multidisciplinary approach.

When it was established that a multidisciplinary group is required to adequately treat wounds, we began to look at how these wounds can be managed with this approach. The way wounds have been treated in the past has been based on what somebody thought worked, or what had been taught to them or what seemed appropriate at the time.

How was EBM wound care first embraced by the medical community and how will it evolve over time?

EBM has been defined as the conscientious, explicit and judicious use of current best practice or proof that something works when making decisions about the care of an individual patient - when you take into account all the proof that something works for your patient when making a decision about the treatment.

Unfortunately, introducing EBM is not as easy as you would think because people don't like change, and when it comes to providing evidence for something, it has been shown that often we want the facts to fit the preconceptions. US author Jessamyn West stated that when facts don't fit our preconceptions, it is easier to ignore the facts than to change the preconceptions. We have found that is certainly the case with EBM; if a wound-care practitioner is enthusiastic about EBM, it implies that the practitioner really cares if the current practices or treatments are actually working. The practitioner will determine if there is evidence for that current practice.

An essential part to the treatment of a patient's wound is experience. What is the balance between experiment and EBM?

I would hope that the two would basically be the same. If you have a lot of experience but don't follow your outcomes and find out the evidence for what you have been doing has been acceptable, then your experience has been worth nothing.

So, part of gaining the experience you need in the treatment of wounds is to be sure that your outcomes are working well and that you have evidence that what you do is appropriate for your patients. The interesting thing that everyone should remember about EBM is that it is not 'ivory-tower' medicine and it is not designed to make 'cookie-cutter' treatments for every type of wound. It does not replace clinical judgment or experience, and it does not replace tailoring care to individual patients, but it does require skill to search for, interpret and use the evidence so that we can choose the best therapy for our patients.

With this drive for EBM, how is evidence determined?

There are many ways to do that and there is evidence to support that. Most people would suggest that a randomised clinical control trial is the gold standard for clinical evidence. In many cases, that is the situation. However, there are other levels of evidence that still includes case-control studies, case series, case reports and even ideas in editorial opinions. It depends on the strength of that evidence and, again, the strongest evidence is considered to be systematic reviewed and randomised controlled, double-blind trials. Unfortunately, we don't have a lot of those in wound care.

With so much information available, how can caregivers be sure they are reviewing and applying the right practices for each case?

I would encourage all practitioners to look at the evidence for all of the treatments that they apply to patients with wounds, to evaluate the available evidence carefully and to see if it might apply to the patients that they are looking to treat. They should never be afraid of changing the therapy for the individual and they should always be on the lookout for better ways to treat patients. I encourage all practitioners to begin generating their own evidence. This is how we can make the treatment of wounds move forward; if all practitioners would evaluate their results with different therapies, it will help wound care progress as we generate our own evidence and not depend on others to do this for us.

How is EMB being applied to current clinical guidelines and will we see a standardisation of wound care?

The benefit of EBM is that if done appropriately, it can provide more consistent care and this may or may not be beneficial, depending on how consistently our patients respond; however, it will result in better outcomes because many of the treatments that have no evidence at all will be eliminated and it will encourage provider education.

On the downside, implied guidelines for care may not apply to all patients and only a limited number may respond to the care because most of the clinical trials treat only a very select group of patients, and then they try to apply that information to all of the patients. Interestingly, we have found that a number of safety issues and outcomes of data may have been eliminated from the information so that we really don't have all of the information that we need.

We have to be very concerned about blindly following evidence-based guidelines, which could lead to a lack of individualised care. We need to be very careful that these guidelines don't lead to patients being treated solely based on them, perhaps missing out on other types of innovative therapies that could be used. We also need to be sure we're able to change the types of treatments used if patients are not responding.

The standardisation of wound care is beginning to occur; however, there are many things that we do not have answers for in the treatment of our patients. The basics of wound care need to be standardised. At this point, we are in desperate need of additional research on the basic science of wound healing, the pathophysiology of wounds and how we can affect this. As we become smarter on these topics, then we will be able to adapt our approaches and treatments so that we can address the issues that are wrong regarding the wound and allow the wound to start healing. Whether or not this will ever be managed by a guideline or a strict outline is problematic at this time and only the future will tell.

What role will EBM play in the management of wounds in the future? Is it likely we will continue to head down this path as the default position?

I encourage every practitioner to evaluate their results with every treatment that they do for every wound they treat, so that they will have their own evidence as to what works for them and their patients. We also need that information to be shared so that we can all benefit from that knowledge - good information and good evidence can come from the smallest wound centre; it doesn't have to come from the mega-wound organisations, universities or research institutes.

Every day, all of us who practise wound care are in the process of developing evidence-based wound care, and we just have to be aware of what we are doing and to accumulate that evidence so that we can share it so that everyone can benefit.