How many of us are familiar with last year's publication of the National Wound Management Guidelines by the Republic of Ireland's Health Service Executive (HSE) (2018)? I would argue that we all should be, in the absence of a comprehensive document from the National Institute for Health and Care Excellence (NICE). It is an important piece of work that develops and revises the HSE's (2009)National Best Practice and Evidence Based Guidelines for Wound Management and is a much-needed update in an advancing technological field that is relevant to our daily practice.
In the present healthcare system, protocols and guidelines seem to dominate the practice landscape and it is often not clear, when one supersedes the next, which current ‘one’ we should be following. The HSE guidelines can be used to fill a knowledge gap in UK-based practice where no comparable document exists to provide a translatable structure for how we manage patients within the NHS.
Our working lives feature a multitude of competing interests vying for our time and attention. Thus, being inundated with dossiers of data can often serve the opposite of their intended purpose: we can be left feeling overwhelmed with knowledge and find it difficult to find the time to piece together the information provided in a meaningful way.
With that in mind, I often find that well-constructed guidelines are a safe harbour in the sea of evidence. In many ways they ‘do all the hard work’ for us, sifting through the evidence and putting together the salient points in a comprehensive guide for use.
Cornerstone of care
Evidence-based practice (EBP) incorporates placing research evidence, clinical expertise and patient needs into the context of modern-day healthcare practice and it remains a cornerstone on which we base our standards of care.
Additionally, it enables us to provide effective treatments and prompts us to wonder why we do things in a certain way. EBP can help address questions such as ‘Why am I doing this in this way?’ and ‘Is there anything I can do to enable me to do this more effectively?’ It also ensures that in centrally pooled funding systems such as the NHS our resources are used wisely and that decisions around funding are made in a balanced way, after considering the available evidence to support, or refute, a treatment or management strategy.
In the UK, EBP ties in closely with some of the financial challenges and, dare I say, frustrations we encounter: it is difficult to justify widespread national care strategies that are not shown to significantly improve patient outcomes in a cost-effective manner.
As a result, there is a strong argument to say that the place for using novel treatments should be in the realms of research, to build a portfolio of evidence that demonstrates clearly that they are better or at least not inferior to accepted standards of care.
The same goes for the anecdotal, opinion-based mentality that says that ‘this is the way it's always been done’. This was largely how many healthcare services were delivered in the era before EBP: we relied on the advice of more experienced, usually senior colleagues, and often took at face value their opinions or what they had been taught themselves as students.
There is much to be said for such experience and of course, it has an important role in the way we work, but experience doesn't always translate into expertise if we cannot demonstrate, through accumulated data and results sustained over time, that what we are doing actually works. Relying on ‘experienced colleagues’ alone can result in relaying dated, biased and inaccurate information and we can run the risk of failing to provide the high quality of care that our patients deserve.
Rather than relying on clinical experience alone, we should remember to question our practice and be open to new ideas. If evidence emerges to challenge our practice by showing that there are better alternatives, then we should adopt them.
Structured assistance
So, what do the HSE guidelines tell us? Aside from being an engaging read, at their heart they provide a standardised framework through which we can work together to deliver consistently high standards of care to our patients.
Changes to the document relative to the 2009 guidance include a more comprehensive take on leg ulceration, for example on ulcers of varying aetiology, and new sections on palliative wound care, as well as a fantastic section on caring for wounds in populations such as people with spinal cord injuries, the critically unwell, obese patients, those in the operating theatre and children, and its recommendations in part draw on NICE guidelines published on these areas.
As a tool to assist the wide range of professionals who deal with wounds every day, these guidelines provide excellent, structured assistance in the decision-making process to provide care. They acknowledge that not everyone has the same knowledge, skills or expertise to deal with wounds, providing a thoughtful structure to enhance wound care.
Furthermore, these guidelines (HSE, 2018) can be used to help us appraise our own current local practices against accepted standards, providing leverage for areas that may be lacking funding or support at a loco-regional level. I suggest that you that read them!