Critical Appraisal - Essay Example

Evidence Based Practice/Critical Appraisal This paper discusses the equipments available for the effective reduction of pressure ulcers, and the background of the study. There is an analysis of the evidence found in the course of the study, as regards the treatment of pressure ulcers, and if the findings could be effective in practice. The paper investigates the methods and search strategy used, and whether the methods used can be replicated and applied in practice. This paper critically analyses a research article on the healing rates of different pressure-relieving systems, which was conducted in 2000 by Russell et al. the paper discusses how the findings of this research can benefit bed-ridden patients and tackles the question of the efficacy of mattresses as pressure relieving equipment in the treatment of pressure ulcer patients. There is also an analysis of the existing research on evidence-based practice in relation to pressure ulcers and a discussion of the factors influencing evidence-based practice in this area. Background This work is related to the activities in an oncology ward, in which patients eat and drink little and remain bedridden for most of the time, and as a result are at a high risk of pressure ulcers. Indeed, many of the patients develop pressure ulcers after admission, which are extremely difficult to heal (Mackleburst & Sieggreen, 2001). This topic examines the equipments available for the effective reduction of pressure ulcers, and has been chosen as a way of discovering how patients suffering from pressure ulcers may be better cared for. This includes the problem of cost to the NHS each year for the treatment of pressure ulcers. This paper will involve a review of the existing research that has been done on this issue to ascertain if there is any equipment available which will help the healing of bedridden patients who suffer from pressure ulcers, and also to prevent future occurrences of pressure ulcers. This involves looking into the question of which equipments might be available for effective reduction of pressure ulcers for patients. A pressure ulcer is ‘an area of localised damage to the skin and to the underlying tissue caused by pressure, shear or friction’ (European Pressure Ulcer Advisory Panel 2003). The higher the intensity of pressure and the longer the duration of pressure, the higher the risk of developing pressure ulcers. Individual ‘tissue tolerance’ will also determine whether pressure ulcers develop (DeFloor and DeSchumer, 2000). It is reported that pressure ulcers develop in up to 32% of hospitalised adult patients and will be on or around bony areas such as the sacrum (Murdock, 2002; Jones and Tweed, 2001). The financial costs to the National Health Service are considered to be substantial; it is estimated that 1.4 to 2.1 billion is spent annually, which is 4% of the NHS budget (Bennett et al, 2004). It is suggested that this can be avoided. Methods The method employed is a POPULATION, INTERVENTION, COUNTER-INTERVENTION and OUTCOME (PICO) process. The aim of the PICO process was to show that implementation of evidence-based practice (EBP) could be achieved using up to date knowledge about managing change within the National Health Service as well as changing clinical behaviour (Dunning 2004). EBP is described as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (Sacket et al, 1977) Recently, a personalized self-management system was developed by the RAT group at the University of Sheffield. This technology, a result of the work done by the multidisciplinary team, is effective in the treatment process of people with long-term illnesses. The study comparing the efficacy of two alternating cell mattress and cushion combinations in the treatment of pressure ulcers in hospital patients also showed successful results. In light of the above information, focus will be placed on discovering the effectiveness of the use of two types of cell mattresses in the treatment of the pressure ulcers. The advantages and disadvantages of the treatment method are found out before applying the treatment procedure, to gain a better idea of its effectiveness (Gerrish & Lacey, 2006). The treatment plan is executed after ensuring that it will bring only benefit to the patient. The scope of the question is important to the preparation for the research, as it will enable me to devise the terms used for the search in the facet analysis. The question is thus asked using PICO (see Appendix 1), which is described by Sackett et al (1997) as making sure that the research process is focused and properly conducted. A search strategy was devised to find the study relevant to the topic, to find out which specific equipments could be implemented to prevent or ease the problem of pressure ulcers in bedridden patients. Search Strategy It is enshrined in the nurse’s code of professional conduct (NMC 2004) that they are expected to practice using evidence-based research, but many have difficulty trying to comprehend the research process (McClarey and Duff, 1997). In preparation for the search needed to complete this report, the research subject had to be clearly defined. A question was devised to enable a proper search; which according to Bowling (2003), is the most fundamental step. The question was based on the assistive technologies used to reduce the pressure to make the patient free of the risk of pressure ulcers. In order to make the research more restricted in its ambit, focus has been placed on two main forms of equipment, and questions were entered using a PICO process: Is the Huntleigh Nimbus 3 Aura cushion mattress as effective as the Pegasus Cairwave therapy system with protective cushion, in promoting the healing rates for pressure sores in adult patients? P I C O POPULATION INTERVENTION COUNTER-INTERVENTION OUTCOME ADULT HUNTLEIGH NIMBUS 3 WITH AURA CUSHION PEGASUS CAIRWAVE WITH PROACTIVE CUSHION PROMOTION OF HEALING OF PRESSURE SORE An analysis of necessary search terms entails searching the current subject and making a list of initial search terms as well as more narrowing terms, so as to narrow down results to those that are relevant to the topic. Initially, the study came up with a list of wide terms, which led to narrow terms, with the aim of searching the broad terms initially, and then adding the narrowing terms to arrive at a suitable selection of relevant articles. The Search engine Cinahl was assessed using the EBSCO interface, while Medline and Embase used the OVID interface. According to Fitzpatrick (2007), these are highly rated by experts. Cinahl has been used for the first search as it is nursing based rather than medical, thus more effective to apply. The initial search was based on the words ‘adult patients’, which was an aim to begin the search as relevant, and broad as possible to be narrowed down. This search was conducted within 3,439 articles, and emphasis was placed on terms related to the desired search. A Boolean operator was applied by entering the word OR to show any terms to bring the article up and provide a broader search, and using the AND operator to narrow it and bring more relevant articles (Cormack, 2000). The facet analysis using PICO is as follows: POPULATION INTERVENTION COUNTER-INTERVENTION OUTCOME ADULT PATIENT ADULT PATIENTS ADULT PATIENT HOSPITAL PATIENT LONG TERM CARE OVERLAY HUNTLEIGH NIMBUS 3 AIR SUPPORT BED AND MATTRESSES BED AND MATTRESS BEDS AND MATTRESSES SKIN/WOUND MANAGEMENT PEGASUS CAIRWAVE WOUND HEALING PRESSURE ULCER PRESSURE CORE DECUBITUS As can be seen, the facet analysis is considered to be an important part of the research activity, as it allows a clearly constructed question to be devised. The question is broken down into four main facets and each can contribute to the main elements of both the question and the research process. The process can be viewed in appendix 1, displaying the words searched, and the available articles after each search. As can be seen, the main search terms, in direct connection with the researched topic included: 1.) adult patients 2.) inpatients 3.) air support 4.) wound healing 5.) beds and mattresses 6.) pressure ulcer The search was limited to clinical trials and nursing journals, giving me the final amount of articles available: 27, of which the first article was chosen, entitled ‘a comparison of healing rates on two pressure-relieving systems’. Because the search engine was set to display results in order of relevance, it was clear that this first article displayed all of the search results that had been entered, within the context in which they had been entered, and this is something not all of the other articles had. The second search was based on the database Medline, in order to obtain an article with a medical perspective. The same search terms were used as those above, but the results included many irrelevant articles. This is possibly because the database is more medical than nursing-based, and thus articles were presented either beyond the researcher’s expertise or purpose, or irrelevant to the searched topic. In order to differentiate this search from the initial search, the phrase ‘randomised comparative trials’ was replaced with the term ‘quasi-experimental studies’. This resulted in 6 hits, all of which were relevant to the topic (see Appendix 2). For analysis, the third article on the list titled ‘A randomized trial of low air-loss beds for treatment of pressure ulcers’ was selected. The reason for this is that, by choosing a different design, it could be ensured that this piece of research would be different from the first in the methodology. The third database used was Embase, in which the same search terms were entered. The process was similar to the previous two, and the results were pretty much the same, except that the narrowed search came up with a larger number of papers overall. However, upon reading the paper abstracts, it was found that they were not as suitable as those found in Cinahl. Initially, Medline was used because it has a large collection of research papers, but this large number in the end proved to be unhelpful, as the searching was difficult to pinpoint to the question that was being researched; the research paper that resulted was not suitable or as relevant to the topic as the Cinahl papers. Below is the table of findings for each database: DATABASE Total number of papers Research papers Study population CINAHL 27 5 Adult MEDLINE 1 1 Adult EMBASE 162 2 Adult The papers that were eventually selected from the wide availability are due to the information contained in them being suitable for the chosen topic. In order to discover how the articles would be suitable, the abstracts of the papers were compared to the chosen topic to discover if they were suitable. The chosen papers, thus shown by the abstract were considered suitable and applicable to the chosen topic. This reading of the abstracts and the narrowing of the search by using more relevant terms, it was possible to allocate the most suitable papers for the research. As earlier stated, a number of practices have been used to narrow the search. As well as using specific search terms, also narrowed the database search to English language papers. Furthermore, the search was restricted to evidence-based practice, so that only these articles would be provided. This omitted the other forms of research, which were not relevant to the study, as the search was carried out for the best method of reducing pressure ulcers for patients. Critical appraisal of research article The study chosen is entitled ‘A comparison of healing rates on two pressure-relieving systems’ and was conducted by Russell et al (2000). Using CASP (2002), an analysis of the effectiveness of the trial as a randomised controlled trial was done. Craig and Smyth (2002) noted that the process of critical appraisal is a way of evaluating evidence and arriving at a conclusion as to how valid it is, and thus how much it can be relied upon. The following paragraphs answer the screening questions of the CASP method. The study is about comparing the efficacy of the mattresses in treating the pressure ulcer patients as a pressure relieving equipment – it has a clearly focused question. The patients who are at a high risk of pressure ulcers are randomly selected using the Watelow score. The significant issue is the prevention of pressure ulcers and how this can be achieved. The effectiveness of different systems is the important thing in the providers’ healthcare. Two alternate cell mattress and cushion combinations in the treatment process are to be tested through the research. The research review question is ‘the effectiveness of adaptation of the new technologies in the treatment of pressure ulcer patients’. The effectiveness means the usefulness and the purposefulness, the adaptation means the updated knowledge and the new inventions based on the updated knowledge, pressure ulcer is the ulcer formed as the result of the long-term medical treatment. The study was carried out by randomized controlled trials of two pressure-relieving systems. The study attempts to compare the efficacy of two alternating cell mattress and cushion combinations in the treatment of pressure ulcers in hospital patients. The study population of the research was 141 patients, 70 of whom were nursed using the Huntleigh Nimbus 3 in conjunction with the Aura cushion, named Group A. The remaining patients used the Pegasus Cairwave Therapy System in conjunction with the Proactive 2 Seating cushion; group B. Patients admitted to the hospital from 17 August 1997 to 31 December 1998 were assessed. When admitted to hospital, the patients were assessed as having grade 2 pressure ulcers. The researchers focused on one hundred patients from two groups, who were recruited under their consent; patients not willing to participate were duly excluded from the study. The two pressure relieving systems used for the study by the researchers are Huntleigh Nimbus 3 with Aura cushion (for the A group), and the Pegasus Cairwave therapy system with the proactive cushion (for the B group). One month was allotted for the pre trial use in order to make the practitioners familiar with the systems. No other systems used on the patients during the time of trial in order to achieve accurate efficiency of each system. The site, progression and severity of the ulcers were recorded at the time of admission of the patients on the basis of hospital information systems. The site of the pressure ulcers were photographed by a medical photographer each week, and the patients were surveyed every seven days of the trial by a medical interviewer in order to understand the rate of progress in the patient. A person not in charge of patient care and equipment was appointed to take statistical monitoring in order to avoid any form of bias, and he was given the responsibility of random bed allocation. Any patients who did not fully complete the trial period were excluded from the results. Despite the fact that 186 subjects were recruited for the study, some of them could not complete the trial due to death. Sixteen patients died from group A, and ten from group B. Even though 112 survived the trial period, some of them could not complete the trial due to various problems. 4 patients withdrew from the trial because they could not sleep on the alternated bed, or had an aversion to the photographs taken of their sores. Table 1 in the research review shows the average and highest severity of the pressure ulcer patients, the number of patients who completed the trial, and the number of patients who died during the study. The second table in the research review presents improvement rates for patients from both groups A and B, and those who died before the trial ended. The study finds that both mattresses are equally effective to prevent pressure ulcers. There were some difficulties with some of the equipment in the first month of the trial since repair was required. Due to the suitability and success of the equipment, a noticeable decrease in pressure ulcers among patients was observed. The research aimed at making patients stay for 18 days, with 100% use of the equipment, although this was not practical in reality. Some patients who suffered severe pressure ulcers did, however, remain for 22 days. The researchers were not aware that the high amount of patients would die (26 overall). The information observed and assessed was kept confidential from the company of the equipment, and the professionals in charge of the patients’ care. It was observed that the equipment caused a high degree of recovery from sacral ulcers. Although there was minute superiority of group A mattresses in the recovery of ulcers, the difference was not adequate enough to record as significant. When the trial was over, it was found that there was no difference between the two mattresses in the improvement of pressure ulcers. Randomization of bed allocation was not successful because the patients who were mostly affected by pressure ulcers were nursed on a better performance surface. The research is considered valid internally since it meets the requirements such as taking the history of the patient into consideration in order to understand the severity of the ulcers, the effects of the various tests, keeping instruments in proper condition, and conducting research morally. The history of the subjects was recorded, according to hospital procedure. The sites and severity of the ulcers were recorded. The medical auditor assessed the situation each day, and the ulcer sites were photographed in order to record any changes. People were given maximum freedom to participate or not in the trial, in accordance with ethical requirements. Subjects were allowed to leave whenever they wished: 2 patients were not comfortable being photographed and a surprising number of deaths of occurred once the trial began. The research findings however remain valid, as patients who died after the beginning of the trial were removed from the trial results. The research results can also be externally applied, as its findings can be generalized to other populations and environments. There was also no external threat since the selection of patients, sampling methods and number of participants was appropriately and properly selected and controlled. The patients’ response was also predicted, and the desired results. The research is reliable since there is little room for bias or instrumental defects. There are three reasons as to why this research can be relied on. Firstly, the ulcer was graded in order to ensure the inter-observer reliability of the research. Secondly, the image analysis made possible by the photographs of the ulcers, which were taken weekly and allowed a visual analysis to be carried out of the rate of recovery of the ulcers. Thirdly, the medical auditor would visit the patients after the trial in order to check the rate of progress. The research was approved and given permission to proceed by the ethical committee, which was very keen to observe and address the ethical issues related to the research. The patients who were enrolled in the trial participated willingly and of their own free will. Implementation Strategy Due to the findings conveying that both equipments are equally effective in preventing pressure ulcers, it could be said that the problem with pressure ulcers is considerably eased for hospitals. It is also clear that evidence-based research is extremely effective in helping the development of health care (Muir, 1997). The problem now lies in the insufficient knowledge of hospitals as to the effectiveness of the equipment, which is thus not able to take advantage of such equipment because they are unaware of its benefits. In implementing this, patients who suffer from pressure wounds, should be informed about the effectiveness of the equipment. In order to obtain the equipment, the findings will be presented so that it may be considered useful to implement them in the ward. The amount of money that would be saved in the long run through not having to undertake pressure wound care will be calculated, as this outweighs the initial costs of the equipment. It is likely that they would be implemented on the ward in question. The research shows the efficacy of the equipments, and so it needs to be released to hospitals so that they are more informed, especially as the results can be generalised. The results are also relevant to others such as nursing staff and family members of patients because it is cost effective and helps to heal the ulcers. The equipment can be used widely because it is based on evidence-based medicine, which makes it results effective and reliable. The attitude of patients towards the equipment may differ, which is important because comfort felt by each patient is a subjective principle. This can only be overcome on a case-by-case basis, to which each patient will be made comfortable as they wish on the equipment. Another barrier is the problem of age; the RCT is carried out on aged persons only, and thus responses of younger patients could vary. In order to prevent these barriers the research must be constantly updated. Further research should be carried out by making the primary research a basis for the further areas to research. Another barrier to implementing this strategy is the issue of cost; the equipment is expensive and hence it may not be feasible for many patients. Further, no control group was set, therefore there exists as chance of the formation of more ulcers in patients using standard matters. The cost of implementation can also have an effect on EBP. Even if the new intervention will ultimately be cost effective, it can place strains on resources, and thus staff members on all levels may be reluctant to change, creating barriers to EBP. However, it is necessary for them to understand that research should only guide practice and not dictate it (DOH 2005). A strategy for implementation would be mainly based on increasing awareness of the equipment and its achievement in reducing pressure ulcers. While the problem of the initial cost is relevant, it could be proven that in the long term, the costs will be less, as money will be saved on a long-term basis. This could be achieved through simple calculations. If the stage can be advanced to the implementation of the equipment, it would also be necessary to train staff in using the equipment, as well as implementing proper strategies for keeping the risk of pressure ulcers low. This would involve training sessions and interactive practices. This is an important step, for without the proper use of the equipment, it will not have the optimal results of reducing pressure ulcers. This needs to be communicated to all staff so that the knowledge and proper use of one is not undermined by the lack of knowledge of another. Overall, if the steps taken are implemented properly, it can prove to be very beneficial for hospitals, patients and the NHS budget over a long period of time. Conclusion Understanding the research behind EBP has been a particularly challenging area of the studies so far. However, using critical analysis throughout this report has enabled me to value the importance of good research. Having done this report, I feel that I have benefited considerably with my self-confidence in research, and as McClarey and Duff (1997) suggest, if a nurse is confident in their own understanding and knowledge, they will be able to provide the best possible care through EBP. There were some initial difficulties in appraising the evidence of the article, but future attempts will be advantageous and will improve my skills through practice. The importance of keeping up to date with one’s education cannot be overstressed, and it can be seen that government policies and guidelines originate from well-designed research. This study suggests that there is no difference between the different mattresses examined, when it comes to improvement of pressure ulcers. Randomization of bed allocation was not successful during the study because the patients who were mostly affected by pressure ulcers were nursed on a better performance surface The findings of this paper are extremely useful, as they can be generalised to all bed-ridden patients, except those of a younger age. However, there seems to be little doubt evident that the equipment would not work for younger patients also. All in all, an answer to the research question was arrived at. Further research into this area would not, however, be useless, and would help to advance such treatment to all types of patients. References Bennett, G., Dealey, C., Posnett, J. (2004). The cost of pressure ulcers in the UK. Age and Aging, Vol 33 Pp 230-235. Bowling, A. (2003). Research Methods in Health, Open University CASP screening questions (2002). Guyatt GH, Sackett DL, and Cook DJ, Users’ guides to the medical literature. II. How to use an article about therapy or prevention. 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London, Churchill Livingstone. Question asked using PICO: Is the Huntleigh Nimbus 3 Aura Cushion mattress as effective as Pegasus Cairwave therapy system with protective cushion in promoting the healing rates for pressure sores in adult patients? Appendix 1 P I C O POPULATION INTERVENTION COUNTER-INTERVENTION OUTCOME ADULT HUNTLEIGH NIMBUS 3 WITH THE AURA CUSHION PEGASUS CAIRWAVE WITH THE PROACTIVE CUSHION PROMOTION HEALING IN PRESSURE SORE Appendix 2 Facet analysis POPULATION INTERVENTION COUNTER-INTERVENTION OUTCOME ADULT PATIENT* ADULT PATIENTS ADULT PATIENT HOSPITAL PATIENT* LONG TERM CARE OVERLAY HUNTLEIGH NIMBUS 3 AIR SUPPORT BED AND MATTRESSES BED AND MATTRESS BEDS AND MATTRESSES SKIN/WOUND MENAGEMENT WOUND MENAGEMENT PEGASUS CAIRWAVE WOUND HEALING PRESSURE ULCER PRESSURE SORE DECUBITUS Appendix 3 Table of findings DATABASE Total number of papers Research papers Study population CINAHL 27 5 adult MEDLINE 1 1 adult EMBASE 162 2 adult Read More