Guidelines for Leg Ulcer Management

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Guidelines for Leg Ulcer Management

• Leg Ulcer Forum
• Irene Anderson and Judy Harker
• Taunton
• May 2005

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Im a guideline, get me out of here!
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Objectives

• Definition
• Development
• Implementation
• Barriers to Implementation
• Guidelines in Clinical Practice
• Your Views

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Definition

• User friendly statements that bring together the
  best external evidence and other knowledge
  necessary for decision-making about a specific
  health problem (Sackett et al, 1997)
• Systematically developed statements to assist
  practitioners and patients to select appropriate
  healthcare for specific circumstances (IOM, 1992)
• Guideline often used interchangeably with
  protocol/policy

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Definition

• Good guidelines dont tell practitioners which
  decision to makeprovide clinicians with evidence
  which, when added to individual clinical
  judgement will help to promote informed choice
  (Sackett et al, 1996)

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Hierarchy of Evidence

• l consistent finding in a majority of multiple
  acceptable studies
• ll either based on a single acceptable study or
  a weak or inconsistent finding in multiple
  acceptable studies
• lll limited scientific evidence which does not
  meet all the criteria of acceptable studies or
  absence of acceptable studies of good quality
  includes published or unpublished expert opinion.

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Evidence Based Practice

• Incorporates quality care, clinical effectiveness
  and consumer choice
• But
• This presupposes there is one optimal solution to
  every healthcare problem (Mead, 2000)

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Evidence Based Practice

• Research
• Clinical experience
• Patients
• Local context - audit, patient stories, culture
  and organisation, professional and social
  networks, leadership and expertise

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Barriers to Understanding Research (McKenna et
al, 2004)

• Research articles are not easily understood
• agree 47.8 disagree 38.8
• Research has conflicting results
• agree 83.1 disagree 5
• More confident if an experienced person supplies
  information
• agree 79.2 disagree 9.4
• Mass of research overwhelming
  agree 72.1 disagree 16.5

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RCN Guidelines

• Technical Report - aims and objectives,
  methodology
• Recommendations summary and evidence appraisal
• Implementation guide (2000) active documents
  audit and feedback

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Implementation

• Education
• Reminders
• Key opinion leaders
• Audit and feedback
• Inclusiveness
• Creativity

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Clinical Reality

• Is your care based on local/national guidelines?
• Is the care you give documented and linked to
  guidelines?
• Have you recorded deviations from guidelines?

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Move over, Im coming in!
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Implementing leg ulcer guidelines

• LUF Study Day 2005

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Systematic reviews

• Bero et al, 1998
• Grimshaw et al, 1995
• Grimshaw and Russell, 1993
• Thomas et al, 1999

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RCN (2000) Implementation Guide
Step 1. Decide who will lead and coordinate work
Step 2. Determine where you are now
Step 3. Prepare people and environment for
guideline implementation
Step 4. Decide which implementation techniques
to use
Step 5. Devise action plan
Step 6. Evaluate progress
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Prepare people and environment for guideline
implementation
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Barriers
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Lack of awareness and knowledge
Seminars and workshops
Knowledge and information by themselves are not
enough to persuade people to change their
behaviour (Freemantle et al, 1997)

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Staff attendance poor
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Identify opponents

• Negative attitudes to guideline
• Plan activities to overcome such attitudes
• Be open and honest about guideline

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Identify supporters
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Perception of increased workload
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Organisational barriers

• May require specific interventions
• E.g. giving Leg Ulcer Clinics the authority to
  refer to vascular studies ensuring direct
  access

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Reduced Clinical Freedom
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Clinicians are unaware of sub-optimal practice
Audit and feedback may be useful
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Existing cultures, practices and routines
Educational outreach Opinion leaders
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Clinicians have problems processing information
within consultations
reminders
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Devise checklist for dissemination
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Decide which implementation techniques to use to
promote use of guidelines
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There is no single effective way to ensure the
use of guidelines in practice
Organisations should use multifaceted
interventions to disseminate and implement
guidelines
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Comparison of different educational strategies

• Interventions requiring professional
  participation
• Interventions linked to clinical decision-making
  are

more likely to lead to successful implementation
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Education and training

• Example of content
• Benefits of guidelines
• How and why developed
• What is needed to implement guideline
• Content of guideline and how applies to staff
• What staff are being asked to
• do with guideline
• How they can use guideline
• How they can monitor its use and
• ensure care is improved

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Devise a consumer version of guideline
PATIENT INFORMATION Every person with a loss of
tissue or break in their skin integrity
will have a formal assessment undertaken by
a suitably trained person within 6-8 weeks of
occurrence
Patient empowerment
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Clinical Leadership

• Gain support of influential / senior figures
• E.g. Director of nursing, G.Ps, chief executives

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Capitalise on social situation

• Discussion with peers
• Social influence may be biggest factor in whether
  new initiative is implemented
• Provide opportunities for discussion
• E.g. utilise team meetings, events usually well
  attended

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Refer to guideline recommendations when giving
advice as specialist nurse
Refer to guideline when investigating clinical
incidents
Involve industry for help in dissemination
Quick reference guides
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