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A Survey of Current Physical Therapy Practices in Wound Care
Currently, a plethora of physical therapy evaluation and intervention techniques is available to the practicing clinician.1-4 However, the literature is sparse for standardized protocols pertaining to wound care, as well as the relationship of demographic factors (eg, hours of continuing education in wound care, years of experience, and percentage of practice involving wound care) to a therapist's choice of evaluation and intervention techniques used in practice. The Agency for Health Care Policy and Research (AHCPR) is one exception - it does have protocols available for pressure ulcer care and prevention.5 Other guidelines available to the clinician, as well as to the physical therapy educator, include The Guide to Physical Therapist Practice6 and the Normative Model of Physical Therapist Professional Education: Version 97 and 99.7
Continuing education (CE) is one venue for advancing professional knowledge. The American Physical Therapy Association (APTA) currently reports that 24 states require some form of CE for relicensure.8 As an increasing number of states begin to legislate CE requirements, more research needs to be done to assess the effectiveness of CE in accomplishing its stated objectives. Available literature fails to examine the impact of CE on patient and disease outcomes.9 Evidence is contradictory as to the long-term effects of CE on clinician knowledge, patient care, and practice patterns.9-11 For instance, in studies on the effects of CE to produce a lasting change in clinician behavior, researchers have found that the change in knowledge acquired during the program lasted 6 months post intervention.10,12 Stross et al9 demonstrated a change in participants' behavior, but was unable to make any conclusions about how long the change would last. Sibley et al11 demonstrated an increase in knowledge of the participants with no overall effect on the quality of care. Literature that compared years of experience, CE, and percentage of practice dedicated to wound care specific to evaluation or interventions in wound care practice was not available.
This study was initiated to assess current physical therapy practices and to determine the relationship of demographic data on evaluation and interventions utilized in wound care.
Methods
Instrument development. The initial content of the survey instrument was developed using information from the Guide6 and the Normative Model,7 from a McCulloch, Kloth, and Myer13 CE conference "Teaching Wound Care for PT Educators," and from a wound educator. Two local wound care experts reviewed the survey before distribution and made suggestions for clarity and content. Following questionnaire revisions, eight physical therapists at two Bismarck, ND hospitals assessed internal consistency. The instrument was found to have an alpha coefficient reliability of 0.75.
In the first part of the questionnaire, demographic information was elicited with open- and closed-ended questions. The demographic information requested included: state in which the clinician currently practices, hours of CE in wound care, years of experience as a practicing physical therapist, number of beds in the facility, percentage of total practice comprised of wound care, types of wounds treated, and the work setting. The main body of the questionnaire was divided into two nine-item subsections that corresponded to wound care information sought as part of the study. A Likert-type scale was used for responses, offering five possible choices ranging from "always" to "never." Respondents were asked to explain reasoning for their choice of "never" on the 18-item subscale.
Sample. The questionnaire was distributed by mail to physical therapists at 170 University of Mary Clinical Education Sites. A cover letter distributed with the survey asked that the receiver forward the survey to the clinician most involved in wound care. Four questionnaires were returned unopened. Of the remaining 166 questionnaires distributed, 96 (57.8%) were returned by the deadline; 31 were excluded from data analysis based on a response that 0% of their practice involved wound care. The final modified response rate was 48.1% (65/135).
Data analysis. Descriptive analysis was used to evaluate demographic data. The data included the location/state the physical therapist practiced, the setting of the clinical practice, number of beds in the facility, years as a practicing physical therapist, hours of CE completed in wound care, percentage of total practice involving wound care, and types of wounds treated. Because the majority of surveys indicated more than one response to the type of setting, as well as types of wounds treated, the score assigned indicates a percentage value for each item within the category. Rationale for not using a specific evaluation or intervention technique also was described.
A chi-square analysis was performed to determine whether significant relationships existed among the demographic data and items in the evaluation and intervention sections of the wound care survey. Hours of CE were grouped into the categories of <10, 11 to 25, and >25 hours. Years of practice were grouped into <5, 6 to 10, and >10 years. The percentage of practice involving wound care was categorized into < 5% and >5%. The Likert scale responses were categorized into three answers; 5 and 4 (75% to 100%), 3 and 2 (25% to 50%), and 1 (never).
Results
The majority of survey respondents were currently practicing in Minnesota (28.8%), and North Dakota (25.7%). Of the total number of respondents, 38% worked primarily in an outpatient setting, followed closely by 30% who worked in an acute care setting. Almost two-thirds worked in facilities with 150 beds or less.
Of the respondents practicing less than 15 years (73%), the majority were in the 6 to 10 year range (42.4%). With respect to hours of CE, 51.5% of the respondents reported attending less than 10 hours of continuing education in wound care. Seventy-four percent of the respondents reported <5% of their practice involved wound care. The majority of wound types reported in the survey were diabetic ulcers (34.1%) and venous insufficiency wounds (29.8%) (see Table 1).
Descriptive statistics were utilized to determine the frequency of responses to evaluation techniques listed (see Table 2). The most frequently used evaluation techniques were pictorial assessment of the wound (Mean = 3.6), edema measurement (Mean = 3.4), and wound tracings (Mean = 2.9). The evaluation techniques utilized least were ankle brachial index (Mean = 1.5) and Doppler studies (Mean = 1.3).
Descriptive statistics were utilized to determine the frequency of interventions presently used in practice (see Table 3). Interventions with the highest frequency of use were whirlpool (Mean = 3.7), sharp debridement (Mean = 3.4), and compression dressings (Mean = 2.9). Pulsed lavage (Mean = 1.4) and ultrasound (Mean =1.8) were the least utilized.
The chi-square analysis revealed a significant (P < .05) relationship between the hours of CE completed by the practitioner and the evaluation and treatment techniques used to care for the patient's wounds (see Table 4). More specifically, significant relationships were found between hours of CE and rubor of dependency (chi-squared(4) = 11.67, p < .05), wound culture and CE (chi-squared(4) = 10.74, P < .05), whirlpool and CE (chi-squared (4) = 13.22, P < 05), and autolytic debridement and CE (chi-squared (4) = 26.73, P < .01). Therapists with <10 hours of CE were more likely to respond that they "never use" the rubor of dependency test (47%) than therapists with >26 hours of CE (23%). Wound culture, however, was more likely to be performed by therapists with <10 hours of CE (62%) than by therapists with >26 hours of CE (46%). Therapists with <10 hours of CE used whirlpool "always" or "very often" more (85%), compared to therapists with >26 hours of CE (46%). Finally, autolytic debridement was more likely to be used "always" or "very often" by therapists with >26 hours of CE (54%) than by therapists with <10 hours of CE (3%).
Statistical analysis also revealed a significant (P < .05) relationship between the physical therapist's years of experience and the techniques employed to evaluate and treat wounds (see Table 5). Significant interactions were found between years of experience and the use of sensory testing with monofilaments (chi-squared (4) = 12.85, P < .05), and years of experience with electrical stimulation (chi-squared (4) = 9.53, P < .05). A greater percentage of therapists with <5 years of experience tended to use monofilament testing "always" or "very often" (50%) as compared to therapists with >10 years of experience (4%). However, 17% of the therapists with <5 years of experience responded that they "never use" monofilament, compared to 40% of therapists with >10 years of experience. Electrical stimulation was more likely to be "never" used by therapists with <5 years of experience (62%) than by therapists with >10 years of experience (20%).
Finally, a significant (P < .05) association between the percentage of practice devoted to wound care and the tendency to use a wound care evaluation or treatment technique (see Table 6). Significant interactions were found between a therapist's percentage of practice devoted to wound care and the use of the rubor of dependency test (chi-squared (2) = 14.37, P < .01), sharp debridement (chi-squared (2) = 7.64, P < .05), enzymatic debridement (chi-squared (2) = 7.52, P < .05), compression dressings (chi-squared (2) = 6.27, P < .05), and autolytic debridement (chi-squared (2) = 9.44, P < .01). Therapists with >5% of their practice comprised of wound care were more likely to "always" or "very often" use the rubor of dependency test (44%), sharp debridement (82%), enzymatic debridement (29%), and autolytic debridement (35%) than therapists with <5% of their practice comprised of wound care. Therapists with <5% of their practice devoted to wound care were more likely to answer "never" use the rubor of dependency test (43%), enzymatic debridement (41%), and autolytic debridement (47%) than therapists with >5% of their practice comprised of wound care.
Of the 18 evaluation and intervention techniques, 11 were "never used" by >30% of the respondents (see Table 7). Respondents were asked to justify their reasoning for not choosing an evaluation or intervention technique. Evaluation techniques were not utilized 34% of the time because other professionals were performing these tasks. Additional reasons given for not using the evaluation techniques included: cost, not unless ordered, time, use another method, don't know what that is, not indicated (pulsed lavage), no protocol, lack of adequate training, and outside the scope of practice (Doppler studies, ankle brachial index, and wound culture). Reasons given for not using the intervention techniques included: not unless ordered, cost, time, use another method (sequential or intermittent compression, ultrasound, electrical stimulation), don't know what that is, not indicated (electrical stimulation, ultrasound), no protocol, outside the scope of practice, and no equipment available.
Discussion
Physical therapists are not actively pursing wound care evaluation techniques - other professionals perform 34% of the evaluations. Also, much of the responsibility for wound care has shifted to other professionals. Respondents noted that the nurse or physician performed many of these techniques. It is the physical therapists' responsibility to educate other disciplines regarding their capabilities in wound care and actively market their services. Determining whether the lack of physical therapy involvement was due to inadequate training, lack of cross-discipline education, or financial constraints set forth by third party payers is important. Possibly, the results were obtained because physical therapists participating in wound care did not have the most recent information regarding evaluation and treatment interventions.
The findings indicate a lack of modality usage to accelerate wound healing, with a frequency of Mean = 1.90 for electrical stimulation and Mean = 1.77 for ultrasound. One explanation for the decline in modality usage may be the lack of treatment parameters or protocols set forth in current literature.4,13,14 This compounds the problem of ineffective treatment of wounds by physical therapists.
According to the guidelines present in the Guide6 and the Normative Model,7 clinicians should show competency in evaluation and intervention techniques. The low percentages reported with evaluation techniques (Doppler: Mean = 1.27. ABI: Mean = 1.49, Venous Filling Time: Mean = 1.83) suggest a need for clinical practice pattern development to move toward outcome-based research and justification of wound care interventions. Further investigation is necessary to determine the reasons for differences between interventions suggested by the Guide,6 the Normative Model,7 and clinical practice. This would allow for higher standards of practice and provide a comparable guideline.
Limitations
The use of a sample that is primarily composed of residents of two states (54.5% from Minnesota and North Dakota together) limits the generalizability of the results to other physical therapists from other states. Findings may be different for other geographic locations. The sample also included a high percentage (74.2%) of therapists who report <5% of their practice being comprised of wound care.
Conclusion
With regard to current PT practices in wound care, pictorial assessment, edema measurement, and wound tracings were the most frequently used evaluation techniques. The most common interventions reported were whirlpool, sharp debridement, and compression dressings.
In terms of the relationship between the clinician's demographic profile and the selection of evaluation and intervention techniques, results indicated that hours of CE had a relationship to use of the rubor of dependency test, wound culture, whirlpool, and autolytic debridement. Relationships also were found between percentage of practice comprised of wound care patients and the use of rubor of dependency test, sharp debridement, enzymatic debridement, compression dressings, and autolytic debridement. Finally, the clinician's years of experience was related to the use of monofilament testing and electrical stimulation.
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