Editor`s Opinion: Providing Evidence-based Care, One Question at a Time

  Every issue of OWM is a reminder that the world of skin, wound, continence, and ostomy care is in a constant state of change. As in most areas of healthcare, we rarely can discuss anything as being black or white, and for every question answered a new one is raised. Moreover, because the answer to the new question probably is obtained only through more research, we may have to wait months, years, or decades to get the answer.   Case in point: in this issue of OWM, Edsberg and colleagues¹ answered one question that has been on my mind for almost 20 years: “Is percent wound area reduction in patients with Stage III and Stage IV pressure ulcers a predictor of outcome?”² In 1994, we found that a clinical assessment of poor nutritional status and reduction in wound area of <39% after 2 weeks of care were independent risk factors for nonhealing of full-thickness pressure ulcers. Since that time, many studies have shown that percent reduction in wound area after 2 to 4 weeks is a predictor of venous and diabetic foot ulcer healing.¹ Also, most pressure ulcer guidelines include the recommendation to assess pressure ulcers for healing after 2 to 4 weeks of care.^3,4 Thanks to Edsberg et al’s work, the evidence base for this recommendation is strengthened. We can only hope the new questions raised by their research will not take too long to answer.

  Risk factor research can be as complicated as the human body. In addition, human beings are in constant contact with, and influenced by, their past and current environments. A large cohort study⁵ of persons with spinal cord injury found that those with less than a high school certificate were 2.06 times more likely to have a current pressure ulcer than those with a bachelor’s degree or higher. But how much data can you collect in one study? As reported by Molon and Estrella⁶ in this issue of OWM, for every risk factor identified, there may be several that could not be included or substantiated. Although the authors answered their research questions, several more queries arose because no single study can provide all the answers we need. But we have to start somewhere.

  Also in this issue, the study by Jones and colleagues⁷ examining the ability of a fecal management system to contain Clostridium difficile is a good start to helping us understand how we may be able to prevent the spread of contamination with this dreaded pathogen. Of course in vitro research imposes important limitations, but the characteristics of C. difficile seriously inhibit our ability to conduct any kind of clinical experiment. So, we continue to build the evidence upon which our practice must be based, one, two, or three questions and answers at a time.

  In the meantime, we manage uncharted territory, interpret what is known for use in clinical practice, use existing knowledge to provide the answers patients need, and celebrate when years of research and the efforts of many yield information that is definitely more than a “maybe.” This information may not be a matter of black and white, but at least it provides a level of evidence that makes us feel comfortable discussing the science of the work we do.

1. Edsberg LE, Wyffels JT, Ha DS. Longitudinal study of Stage III and Stage IV pressure ulcer area and perimeter as healing parameters to predict wound closure. Ostomy Wound Manage. 2011;57(10):50–62. 

2. van Rijswijk L, Polansky M. Predictors of time to healing deep pressure ulcers. Ostomy Wound Manage. 1994;40(8):40–48. 

3. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Available at www.guideline.gov. Accessed September 12, 2011.

4. Association for the Advancement of Wound Care (AAWC). Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. Available at www.guideline.gov. Accessed September 12, 2011.

5. Saunders LL, Krause JS, Peters BA, Reed KS. The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury. J Spinal Cord Med. 2010;33(4):387–395.

6. Molon JND, Estrella E. Pressure ulcer incidence and risk factors among hospitalized orthopedic patients: results of a prospective cohort study. Ostomy Wound Manage. 2011;57(10):64–69.

7. Jones S, Towers V, Wishin J, Bowler P. Clostridium difficile containment properties of a fecal management system.