Taking Accountability for Researching & Implementing Evidence-Based Medicine

The wound care industry continues to change at a rapid pace. Sometimes, it may seem impossible for clinicians to remain current on the most recent education and best practices when considering all the challenges we encounter while managing the various vital components of our wound clinics. Seeing this firsthand, I know well that it takes the efforts of dedicated individuals to accomplish clinical and financial success in the clinic. However, the responsibility of clinicians to continue their education and to ensure best practice delivery remains of the utmost importance for us all. How can we keep up with the changes that exist and continue to learn and apply education related to evidence-based practices within our clinics? It’s an overwhelming undertaking for sure. This article will share some insight and advice for the busiest of wound clinic program managers to consider when addressing this issue for themselves and their employees.

The Evidence-Based “Era”

We live and work in an era of evidence-based medicine (EBM), which is defined by the National Academy of Medicine (formerly the Institute of Medicine [IOM]) as the “integration of best research evidence, clinical expertise, and patient values in making decisions about the care of individual patients.” The goal of EBM is to adopt specific current knowledge to make decisions that will improve patient care and, eventually, outcomes. EBM requires time, skill, and a personal attitude and commitment to change.¹ Sometimes, I have a difficult time utilizing EBM, as other factors such as “revenue-based practice,” insurance restrictions, the patient’s ability to follow specific care planning, practitioners working in silos, and limiting usage of available products will influence best practice decisions. EBM is comprised of three components: best research evidence, clinical expertise, and patient values and preferences. Clinical research has been defined as the study of health and illness in people; the way we learn how to prevent, diagnose, and treat illness.² Research evidence comes in various forms, but clinicians must decipher through their information in order to identify it. When it comes to learning best research evidence, I sometimes wonder how clinicians learn about current research while working in a busy clinic that may offer only limited (and perhaps outdated) educational resources. If you look at statistics for the use of total contact casting to offload diabetic foot ulcers and compression for venous wounds from sources such as the U.S. Wound Registry (USWR), the data claims that providers are not conducting best practice. While these numbers have improved, we still have a ways to go to be consistent with evidence-based practices as an industry.  With a commitment to studying clinical research comes “clinical expertise,” which refers to the clinician’s cumulated experience, education, and clinical skills.³ This type of expertise, in my opinion, can vary greatly from provider to provider, as there’s no current standardization of wound care education. Instead, there are wound care certifications and emerging academic programs for clinicians to increase their education and skills. One study provides evidence that nurses who are certified by an accredited provider perform at a higher level than those who are not.⁴ In the field of wound care as a whole it’s evident that the level of education, expertise, and skills is also varied, which indicates that the mere presence of specialized wound centers does not necessarily mean that best practices will be followed across the board. 

The third component of EBM relates to the notion that our patients bring their own unique experiences, preferences, concerns, and expectations into our clinics every day. Patients’ preferences can include their level of involvement in making their own healthcare decisions, their religious or spiritual values, their social and cultural values, their values associated with quality of life, their personal priorities and goals, and their general beliefs about healthcare and personal responsibility for their own healthcare.⁵ This is where the patient becomes an active participant. If you consider yourself to be a patient advocate, I encourage you to ensure all patients are made aware of all available options (and not just what you think they want.) Do not offer amputation just because a treatment failed, especially if you can’t honestly admit that the treatment followed current EBM given the patient’s situation.

READ MORE: LET'S BE FRANK

Education & EBM

When it comes to education for the clinician, I can’t imagine not attending national and regional conferences such as the Symposium on Advanced Wound Care (SAWC) to learn about current applicable information from our peers. This year, SAWC celebrated its 30th anniversary during the spring show in San Diego, CA. In my opinion, SAWC is one of the top wound care conferences to attend. Both clinical and academic experts are onsite to present topics based on current issues, reimbursement, clinical guidelines, and other topics that guide us all in the direction of EBM. Industry is also well represented and representatives from various companies provide opportunities to learn about new products and the science behind those products. Additionally, a massive poster hall is available for in-person educational demonstrations. Still, what resonated most from my recent SAWC experience was overhearing statements such as: 

• “Why change what we’re doing when things are working just right for us and that’s how we’ve done it for years?”
• “These changes won’t affect us.”
• “I take care of the patient and others worry about finances.”

The likelihood that wound care clinicians will continue to exist and be paid in the future is based on the actions that we take now. We need to spend more time collectively learning about how topics such as quality measures, payment reform, and coding and reimbursement will affect us and what we need to do in order to keep our profession sustainable. A research paper published in the mid-1990s found that only 12% of general practitioners who expressed an interest in attending an education course subsequently enrolled in the course.⁶ 

This remains a concern today, even when considering that events like SAWC are well attended. Sometimes it’s difficult to determine what’s more concerning: the idea that interest among some practitioners in educational conferences is low or that, for those of us who do attend these types of events on a regular basis, we tend to bring back a lower level of focus and enthusiasm into our clinics when we return from these motivating types of environments. Based on my experiences, and perhaps based on the aforementioned types of data from organizations such as the USWR, it seems that too many course attendees fail to implement into their daily practices the very standards that they’re educated on while at these conferences. If we are supposed to be an evidence-based industry, shouldn’t we all have an easier time of applying what we’ve learned into our field? 

My question (and my challenge) to those program managers reading this column is: How are you learning about current practices and how effectively are you translating that new knowledge into practice? To be fair, many of us are facing financial constraints, lack of resources, lack of administrative support, and time constraints. All of these challenges can impact one’s availability to travel to seminars. Another limitation that we certainly can’t avoid is the need to achieve insurance and payer approval. Our clinical decision-making tree will vary depending on various insurance standards that occur throughout the country. But, then again, I’d like to see more of us take more professional responsibility in the face of these challenges for the sake of quality patient care. In an effort to help the cause, what follows is a list of leading EBM resources:

• BMJ Clinical Evidence: www.clinicalevidence.com
• Cochrane Database of Systematic Reviews: www.cochranelibrary.com/cochrane-database-of-systematic-reviews
• DynaMed Plus^®: www.dynamicmedical.com
• ClinicalKey^®: www.clinicalkey.com 
• Essential Evidence Plus: www.essentialevidenceplus.com
• University of Kansas SUMSearch: https://sumsearch.org
• Trip (Turning Research Into Practice): www.tripdatabase.com
• University of  York Centre for Reviews and Dissemination: www.york.ac.uk/crd/about
• Institute for Clinical Systems Improvement: www.icsi.org/knowledge
• Agency for Healthcare Research and Quality: www.guidelines.gov
• Preventative Services Task Force: www.uspreventiveservicestaskforce.org

In 2003, the IOM’s Committee on the Health Professions Education urged healthcare professionals to address five core competencies essential to evidence-based practice and quality. These guidelines include:

1. Provide Patient-Centered Care: identify, respect, and care about patients’ differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision-making and management; continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.
2. Work in Interdisciplinary Teams: cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.
3. Employ Evidence-Based Practice: integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.
4. Apply Quality Improvement: identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; design and test interventions to change processes and systems of care (with the objective of improving quality).
5. Utilize Informatics: communicate, manage knowledge, mitigate error, and support decision-making using information technology.

Conclusion

If we as an industry are really committed to doing what’s right for patients, then let’s make sure we’re implementing and practicing EBM and staying informed of current changes via various educational sources. The level to which each of us holds ourselves accountable to learning about current best practices will ultimately affect our patients’ outcomes. It can be very disheartening to see clinics that concentrate on advanced care without instituting basic principles. Let me leave you with a statement from the International Council of Nurses: “Changing practice requires confident, well-supported practitioners, as it is they who are ultimately accountable for their own practice. They need to be empowered to make changes and will need skills such as negotiating, selling, consensus building, and, of course, risk-taking. A healthcare team committed to evidence-based practice finds it easy to share their knowledge and teach others, and this can be an additional motivation.”⁷ 

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapist/wound care consultant at Louisiana Extended Care Hospital, Lafayette, LA; and physical therapist/wound care consultant at Cane River Therapy Services LLC, Natchitoches.