Literature Review Presentation - A. Raley

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Literature review Evidence-based findings in treating diabetic foot ulcers:

Literature review Evidence-based findings in treating diabetic foot ulcers By: Ashley Raley Maryville University


Treatment of diabetic foot ulcers 10 original research articles reviewed Significance of topic researched Search History Description of Wound treatments Negative pressure wound therapy (NPWT) Advanced moist w ound therapy (AMWT) Themes Increased rate of tissue granulation formation Lessened risk for lower limb amputation Reduction in wound surface area Critique of Evidence Gaps in the Evidence Comparison to Nursing Practice Evidence-based Findings Overview


Introduction Diabetic population – treating those with diabetic foot ulcers Often require extensive long-term treatment Related to underlying pathology such as neuropathy, ischemia, and infection Negatively impacts a patient’s health I mportance of providing the most effective treatment is crucial “Approximately 56% of diabetic foot wounds become infected during their life cycle, and 20% of these patients with infected foot wounds require radical debridement of soft tissue and bone, resulting in some form of lower extremity amputation” (Wu & Armstrong, 2008, p. 11). Goal is to prevent future complications


PICO What is the best treatment? Health professionals often face the challenge of determining the best wound care treatment in treating diabetic foot ulcers There are several types of wound care treatments available in treating stage II and stage III diabetic foot ulcers Literature review is focused on answering the following PICO question: Among diabetic patients with foot ulcers (P), does use of negative pressure wound therapy (I) versus moist wound therapy (C), accelerate tissue granulation (O)?

Search History:

Search History Extensive search using the following databases: CINAHL ERIC Cochrane Database of Systematic Reviews Medline All primary research articles reviewed were retrieved from the CINAHL database, as the chosen topic i s nursing specific. Keywords searched: negative pressure wound therapy, moist wound therapy, diabetes, foot ulcers, nursing, foot care education, and vacuum -assisted wound closure (V.A.C.) Limiters set P ublication dates between years 2000-2011 Checking advanced options in CINAHL– “Peer Reviewed”, “Research article”, Evidence-based practice”, and “Randomized Controlled Trials” A total of 81 manuscripts were retrieved Focus of search was based on the diabetic population with foot ulcers who were treated with negative pressure wound therapy or advanced moist wound therapy

Description of Treatments:

Description of Treatments Negative pressure wound therapy: Non-invasive vacuum assisted closure system Subatmospheric pressure: 75 to 125mmHG ( continuous or intermittent pressure ) Placement of foam dressing into wound cavity Connected to portable vacuum pump Closed sealed system Advanced moist wound therapy: Standard of care for treating diabetic foot ulcers Gauze moistened with 0.9% saline placed in wound bed and covered with dry gauze Use of topical agents Hydrogel, standard foam dressings, alginates, and hydrocolloid gel

Theme I Increased Tissue Granulation Formation:

Theme I Increased Tissue Granulation Formation NPWT Allowed for removal of excess exudate on a continuum Increased capillary responses Sealed moist-wound healing environment to promote acceleration of tissue granulation AMWT D id not significantly increase capillary responses Did not provide a closed moist wound-healing environment Required more frequent dressing changes Majority of research studies reviewed: AMWT experienced slower tissue granulation rates and increased time in achieving wound closure Only one study indicated that there was not a significant difference in rate of tissue granulation formation between the two treatments

Theme II Lower Incidence of Lower Limb Amputation:

Theme II Lower Incidence of Lower Limb Amputation As a result of increased tissue granulation formation: With use of NPWT in comparison to AMWT Lower incidence of lower limb amputation Fewer complications Signifies importance of receiving the most effective treatment High prevalence of diabetics who have foot ulcers who have not received the most effective treatment often have a slower wound healing process and greater risk of complications. Diabetic foot ulcer account for the most non-traumatic lower limb amputations in the diabetic population (Wu & Armstrong, 2008).

Theme III Reduction in Wound Surface Area:

Theme III Reduction in Wound Surface Area Patients treated with NPWT achieved g reater reduction in wound surface area at the end of each study reviewed in comparison to those treated with AMWT. Study performed by Akbari, et. al. (2007) – Mean foot ulcer surface area decreased from 46.88mm 2 to 35.09mm 2 using NPWT and 46.62mm 2 to 42.89mm 2 using AMWT It is important to choose a wound treatment that addresses the underlying condition In most cases, diabetic foot ulcers are a result of underlying conditions such as poor blood flow to the lower extremities NPWT promoted increased blood flow to the wound bed by means of localized pressure, resulting in reduced wound surface area Increased capillary filling aides in acceleration of tissue granulation which results in reduced wound surface area

Critique of Evidence:

Critique of Evidence Questions raised in regards to the v alidity and reliability of research findings based on the following: Sampling sizes Designs of studies – Retrospective Studies and Randomized Control Trials Data collection processes

Overview of Research Studies:

Overview of Research Studies Only objective data collected A ll quantitative studies Methods and instruments appropriate and effective in testing the variables Layout and presentation of each article was organized Researchers utilized tables and charts Illustrated statistical findings of the variables tested for each study

Sampling Methods:

Sampling Methods Majority of research articles reviewed Sampling methods were vague Inclusion/exclusion criteria listed Potential bias in choosing participants Randomization of participants In some instances greater portion of participants received NPWT versus AMWT Small sample sizes Precluded statistical significance Not a true representation of population Studies were found to be of low generalizability

Randomized Control Trials versus Retrospective Studies:

Randomized Control Trials versus Retrospective Studies Randomized Control Trials – Smaller sample sizes Challenge for researchers to recruit participants who met the inclusion/exclusion criteria Larger sample sizes needed Retrospective Studies- Benefit of obtaining all data via computer databases Access to larger population for greater representation of the diabetic population

Randomized Control Trials versus Retrospective Studies:

Randomized Control Trials versus Retrospective Studies Randomized Control Trials Researchers evaluated wound characteristics and healing process of the experimental and control groups first-hand Provided consistency in obtaining data Retrospective Studies All data collected from computer data bases Second hand information obtained No opportunity to visually assess wound characteristics or progression of wound healing Risk for bias in choosing patient charts


Strengths/Limitations Strengths In-depth background information and a literature present for each article Purposes of studies fulfilled Conclusions to hypotheses reached Purpose and findings of each study are applicable to nursing Limitations Level of evidence is of low ranking Need for larger randomized control trials More effective in testing efficacy of NPWT in comparison to AMWT Need for more longitudinal studies Provide stronger evidence Future studies that are conducted over a longer duration to evaluate length of time to achieve 100% wound closure

Gaps in Evidence:

Gaps in Evidence How does NPWT affect quality of life? All studies reviewed were quantitative in nature No evaluation of patients’ experiences or perceptions regarding use of NPWT versus AMWT How was patients’ pain managed? No indication as to whether patients receiving NPWT or AMWT experienced greater pain NPWT contraindicated for use in diabetic patients with foot ulcers containing necrotic/non-viable tissue. What type of wound treatment would be most effective in treating diabetic foot ulcers that have increased level of vascular compromise? How accessible and affordable would it be to initiate NPWT versus AMWT? Comparison of cost effectiveness

Comparison to My Practice:

Comparison to My Practice PICO: Among diabetic patients with foot ulcers, does use of negative pressure wound therapy versus moist wound therapy accelerate tissue granulation? The answer to this PICO question is vital to nursing and my practice in the home health setting. Currently care for several patients who have recurring diabetic foot ulcers In my practice: U se of NPWT has resulted in wound healing in a shorter time frame with less complications and requires less frequent dressing changes However, most patients I care for receive AMWT and often require an extensive amount of time to achieve wound closure and often experience recurrence of ulcers It would greatly benefit patients to find what is best practice to promote healthy tissue formation and prevention of complications

Barriers :

Barriers Physicians lack of awareness of the efficacy of NPWT in comparison to AMWT Increased costs for NPWT Denial of insurance authorization for treatment Although NPWT is more expensive than AMWT, in the long run which is really more costly?


Discussion Research indicates that use of NPWT is superior to AMWT and considered best practice for treating diabetic foot ulcers resulting in the following: Increased portion of newly epithelialized wounds Increased tissue granulation rate Fewer complications such as lower limb amputations Decreased wound surface area Majority of studies: Increased risk for bias and decreased validity due to the following: Inadequate sample sizes Low generalizability Less rigorous designs conducted in studies Retrospective studies were not the most rigorous design Larger Randomized Control Trial would be the most rigorous type of study Ambiguity of data collection processes Retrospective studies – Second-hand information collected Reliability and validity of the results are not as strong as they need to be to significantly impact nursing practice at this point.


References Akbari, A., Moodi, H., Ghiasi, F., Sagheb, H., & Rashidi, H. (2007). Effects of vacuum- compression therapy on healing of diabetic foot ulcers: randomized controlled trial. Journal Of Rehabilitation Research & Development, 44( 5), 631-636 . Armstrong, D., Lavery, L. Abu-Rumman, P., Espensen, D., Varques, J., Nixon, B., & Boulton, A . (2002). Outcome of atmospheric pressure dressing therapy on wounds of the diabetic foot . Ostomy Wound Management, 48 (1), 64-68. Blume, P., Walters, J., Payne, W., Ayala, J., & Lantis, J. (2008). Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care, 31 (4), 631-636 . Bondokji, S., Rangaswarny, M., Reuter, C., Farajalla, Y., & Mole, T. (2011). Clinical efficacy of a new variant of a foam-based NWPT system. Journal of Wound Care, 20 (2), 62-67.


References Etöz, A., Özgenel, Y., & Özcan, M. (2004). The use of negative pressure wound therapy on diabetic foot ulcers: a preliminary controlled trial. Wounds: A Compendium of Clinical Research & Practice, 16 (8), 264-269. Frykberg , R., & Williams, D. (2007). Negative-pressure wound therapy and diabetic foot amputations : a retrospective study of payer claims data. Journal of the American Podiatric Medical Association, 97 (5), 351-359 . Lavery, L., Boulton, A., Niezgoda, J., & Sheehan, P. (2007). A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care. International Wound Journal, 4 (2), 103-113 . McCallon, S., Knight, C., Valiulus, J., Cunningham, M., McCulloch, J., & Farinas, L. (2000). Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Management, 46 (8), 28-34 .


References Noble-Bell, G., & Forbes, A. (2008). A systematic review of the effectiveness of negative pressure wound therapy in the management of diabetes foot ulcers. International Wound Journal, 5 (2), 233-242. Page , J., Newswander, B., Schwenke, D., Hansen, M., & Ferguson, J. (2004). Retrospective analysis of negative pressure wound therapy in open foot wounds with significant soft tissue defects. Advances in Skin & Wound Care, 17(7), 354. Stansby , G., Wealleans, V., Wilson, L., & Morrow, D. (2010). Clinical experience of a new NPWT system in diabetic foot ulcers and post-amputation wounds. Journal of Wound Care , 19 (11), 496-502. Ubbink, D., Westerbos, S., Evans, D., Land, L., & Vermeulen, H. (2011). Topical negative pressure for treating chronic wounds. Cochrane Database Of Systematic Reviews, 2 , 1- 32.


References Wu, S., & Armstrong, D. (2008). Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care. International Wound Journal, 5, 10-16.

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