Type Of Article And Level Of Evidence

Published Date: 02 Nov 2017

Abstract

Gauze dressing has long been used as a simple wound dressing. Recently, studies have shown that moisture is a factor in dressings that will help increase a wound rate of healing. To assess the clinical evidence supporting the use of hydrocolloid dressings versus simple gauze dressings in the treatment of pressure ulcers, many relevant studies, between 2004 and 2013, were reviewed. These literatures provide comparative studies and statistics to support the use of hydrocolloid dressings, in aspects such as an increased healing rate, and reduction of wound dimensions. The databases explored included CINAHL, Medline, Biomed Central, JBI institute and the Cochrane Collaboration. All studies were determined to have sufficient methodological standard. However, the studies were also critiqued in regards to any indeterminate protocol that may undermine their validity. The results and reviews of these studies favoured the idea that hydrocolloid dressings were of higher efficiency in increasing the healing rate of pressure ulcers, in comparison to simple gauze dressings. Furthermore, the studies established that the use of hydrocolloid dressings was more cost effective, and time effective, in comparison to simple gauze dressings. The researcher’s rationale present for the choice of the question, which forms the basis of the research, was adapted to determine the best possible treatment for pressure ulcers in a clinical setting.

1.0 Background

1.1 Aim: The aim of this study is to assess literature which supports the use of hydrocolloid dressings in comparison to simple gauze dressings, in regards to an increased healing rate.

1.2 Purpose: The purpose of this study was to determine whether the use of hydrocolloid dressings increased the healing rate of pressure ulcers. Hydrocolloid dressings are favoured for the treatment of pressure ulcer wounds by many Health Care Workers. However, simple gauze dressings are still widely used, and within this study, there will be an analysis on the two dressings, to determine whether there is a difference in the healing rate of pressure ulcer wounds.

1.3 Scope: This review is for academic purposes only. However, in order to acquire the best available evidence for this paper, systemic reviews were gathered, and appraised, from many various databases.

1.4 Literature Search Strategy: The design of this literature review was intended to appraise published studies only. Initially, the search terms used to identify published articles were hydrocolloid dressings, pressure ulcers and dry gauze dressings. The search of publish articles was further narrowed down to a time period between January 2004, and March 2013. The examined databases included CINAHL, Medline, Pubmed, JBI institute and the Cochrane Collaboration. To further examine selected research articles, a student’s checklist, developed by the lectured, was harnessed, established by the work of the Joanna Briggs Institute, and the Cochrane Collaboration. This checklist assessed a methodological value through the use of items such as research design, description of intervention, outcome measures, results and author conclusions.

2.0 Evaluation of the Literature

2.1 Introduction:

Amongst the elderly and immobile population, pressure ulcers are largely prevalent issue. Pressure ulcers are defined as localized skin damage to areas of the body, as a result of constant pressure or friction on that particular site (Moore & Cowman 2012). Various methods of treatment are available to aid the healing process of pressure ulcers. A form of treatment that can be considered is the correct form of dressing, chosen from the severity of the pressure ulcer. These pressure ulcers are graded from grade I-IV, using Striling’s pressure ulcer severity scale (Pedley 2004). Hydrocolloid dressings can be used as a primary dressing on pressure ulcers, by providing a barrier against outside microorganisms, whilst keeping the interior environment of the dressing at an adequately moist level to promote wound healing (‘Hydrocolloids’ 2011, p 156). This superb performance in wound healing makes hydrocolloids a strong rival against the traditional gauze dressing. In order to determine the efficiency of hydrocolloid dressings, in comparison to simple gauze dressings, five articles were critiqued, and their strengths and limitations were explored. These five articles provided a variety of evidence levels, ranging from level I to level III-III (Richardson-Tench et al. 2011, pp 12).

2.2 Critical Appraisal:

The first article analysed was a systematic review by Heyneman et al. (2008) (See appendix 6.1). This article was a qualitative study which presented with level l evidence (Richardson-Tench et al. 2011, pp 10-12). The systemic review came to the conclusion that in regards to grade ll & grade ll pressures ulcers, hydrocolloid dressings were more efficient in the rate and reduction of pressure ulcers, and the time needed for dressing changes, in comparison to simple gauze dressings. A strength of the article is the reliable evidence provided to support this conclusion. The evidence is deemed reliable through the paper’s thorough assessment of twenty-nine publications, which met inclusion criteria of being randomized controlled trials, in which pressure ulcers were managed with a hydrocolloid in the experimental and/or controlled group. Randomized controlled trials and systemic reviews are considered to be the ‘gold standard’ for assessing a method of treatment, due to the delivery of reliable information (Heyneman et al. 2008, pp 1166). Additionally, this article appraised various other dressings, besides gauze and hydrocolloid dressings, in the treatment of pressure ulcers. The results which compiled the basis of the study were presented in a comparative table, which highlighted the healing rate, wound characteristics, dressing characteristics, severity, and study period of pressure ulcers. A particular limitation present within this article is the inclusion of studies with methodological flaws such as an absence of power calculations, blinded assessments, correct randomisation procedures, standardised measuring methods, and intention to treat analyses. The lack of publication year limitations could also be considered a flaw, due to lack of reliability and research guidelines within older articles. Further research is required to clarify the appropriateness of products and their affect on the wound bed.

The secondary article by Horkan et al (2009) focused primarily on the analysis of other systemic reviews of modern dressings promoting wound healing (See appendix 6.2). The extensive analysis of 13 systemic reviews and meta-analysis papers led the article to conclude that there is good evidence to demonstrate that hydrocolloid dressings improve the rate of pressure ulcer healing, in comparison to simple gauze dressings. The paper’s use of systemic reviews provides level l evidence to support its conclusion (Richardson-Tench et al. 2011, pp 10-12). The systemic reviews and meta-analysis studies focused on compared various different dressings, and their affects and a variation of different wounds. To keep the topic relevant to this literary analysis, the researcher of this essay has specifically focused on the areas which make comparison between hydrocolloid dressings, and gauze dressings, in relation to the healing of pressure ulcers. Strengths present within the Horkan et al (2009) paper are things such as the analysing of papers with the implication of randomised controlled trials, which provide reliability, and a good combination of all the data provided from the systemic reviews assessed (Heyneman et al. 2008, pp 1166). However, there are limitations present within the paper than may reduce the validity of it. These limitations are the use of articles with particular factors that reduce the validity of the results. These factors are things such as the small sample sizing, publication bias and a poor methodological quality of the papers reviewed (Horkan et al. 2009, p 304). Lacking study homogeneity from all the articles reviewed, in terms of controls, interventions, endpoints and methodologies, may make an overall comparison difficult to complete, due to the large variations in the studies (Horkan et al. 2009, p 304).

The aim of the cohort study by Bergstrom et al (2005), which provides level III-II evidence, is to identify the wound and treatment characteristics which are associated with stage II to IV pressure ulcers (See appendix 6.3). The result of the study was a greater decrease in the size, and an increase in the healing rate, of stage II pressure ulcers which were dressed with a moist dressing, in comparison to a simple gauze dressing. Strengths present within this study are factors such as a probability value of p <0.001, which makes the study statistically significant, the use of trained data abstractors abstracting data from resident records, resulting in a greater precision in treatment documentation, and a clear linking of the statistical evidence to the research question (Richardson-Tench et al. 2011, pp 61) (Du Prel et al. 2009) (Bergstrom et al. 2005, p 1728). Limitations that are present in this study are things such as highly variable plans of patient care, which resulted in a variety of different treatment models, and an absence of the processes of care which are typically associated with studies with a large database (Bergstrom et al. 2005, p 1728). The use of a convenience sample can also be considered a limitation. It can introduce bias into the sample, therefore making it an inadequate representation of a population, which can prevent the study results from being generalized (Lunsford 1995, p 110).

Level III-III evidence was provided by an article by Jones (2006) (Richardson-Tench et al. 2011, p 12) (See appendix 6.4). This article referenced various other sources to outline the benefits of modern wound dressings, in comparison to simple gauze dressings. The article outlines the ability of hydrocolloid dressings to retain a moist environment, thus decreasing the risk of maceration. The paper states that numerous studies have highlighted an increased healing rate, a decrease in the size, and a decrease in the dressing change frequency of pressure ulcers and chronic wounds, in comparison to gauze dressings. The paper by Jones (2006) also refers to meta-analysis of randomised controlled trials demonstrating a clinical and statistical significance of hydrocolloid dressing over gauze (Jones 2006, p 81). A strength present within this paper is the ability to bind together various different relevant sources and studies to support the use of modern dressings over traditional gauze ones (Richardson-Tench et al. 2011, p 57). Limitations present within this study were things such as a lack of statistical evidence being cited within the article to support the author’s contention, and an unclear conclusion in relevance to the wound itself (Richardson-Tench et al. 2011, p 60).

3.0 Evaluation of the Main Research Article

3.1 The study overview:

This randomised controlled trial, developed by Hollisaz et at (2004), focused on comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers. This article presented level II evidence, due to its nature of being a single blinded randomised controlled trial (Richardson-Tench et al. 2011, p 12). Ninety-one stage I and II pressure ulcers present on 83 male paraplegic patients were assessed in the study. The patients were allocated to phenytoin, simple gauze, and hydrocolloid dressings. The presence of more than one pressure ulcer per patient, as well as only a single blind experiment, could affect the patient’s results. These results were all presented within a comparative table, with the duration, ulcer size and probability value displayed. Furthermore, the overall probability value in most cases was statistically significant. The overall results of the study demonstrated an increased efficiency in wound healing rate, in regards to the use of hydrocolloid dressings rather than simple gauze dressings. To increase the validity of the study, a double blind technique could have been used, as well as a larger sample size, to make it more relevant to the generalized population.

3.2 Type of article and level of evidence:

This study presents with level II evidence, due to its nature of being a single blinded randomised controlled trial (Richardson-Tench et al. 2011, p 12). It would also be considered a quantitative study due to collection of the information under conditions and manipulation (Richardson-Tench et al. 2011, p 10).

3.3 The study design:

In this randomised controlled trial, 2015 male spinal cord injury patients, between the ages of 36.64 ± 6.04 years and weight of 61.12 ± 5.08kg, were initially sampled. From this sample, only 151 patients with 165 pressure ulcers were assessed for their eligibility. These 151 patients were assessed using the inclusion and exclusion criteria. The inclusion criteria present was paraplegia caused by spinal injury, stage I and II pressure ulcers, and patient consent. Exclusion criteria present was addiction, heavy smoking, and the presence of concomitant chronic disease. After this assessment of eligibility, 83 patients with 91 ulcers were selected and allocated into three different groups using the technique of stratified randomization. The use of stratified randomization will reduce the incidence of "sampling bias". Once the sample group was divided, 27 patients with 30 ulcers were allocated to simple dressings, 28 patients with 30 ulcers were allocated to phenytoin, and 28 patients with 31 ulcers were allocated to hydrocolloid dressings. The trial lasted for 8 weeks, and the patients ulcers were assessed every two weeks by general practitioners. At the end of the 8 weeks, all of the ulcers were examined blind by one author, and assessed by the status of healing.

3.4 Statistical analysis

Overall, the study deduced that hydrocolloid dressings were of highest efficiency in treating stage I and II pressure ulcers, when compared to phenytoin and simple gauze dressings. The study demonstrated 74.19 % of the subjects using hydrocolloid dressings having a complete healing status, in comparison to simple gauze dressings, where only 26.66% of the subjects had a complete healing status. These results were considered statistically relevant, with a probability score of less than 0.01, implying that the probability of error is less than 1 percent. By the end of the 8 weeks, 30% of the ulcers dressed by a simple gauze dressing were worsened, 26.66% were not improved, and 16.66% were partially improved. In comparison, 6.45% of hydrocolloid dressings were worsened, 6.45% were not improved, and 12.58% were partially healed. This difference demonstrates that at the end of the trial, more patients with pressure ulcers being dressed by hydrocolloid dressings were completely healed, in comparison to those dressed by gauze dressings. This may indicate a faster healing rate of pressure ulcers dressed with hydrocolloid dressings, due to the larger amount of pressure ulcers which had completely healed by the end of the trial.

3.5 Outcomes/Results for Nurse and Patient:

The outcome of this paper demonstrated that hydrocolloids were favoured in regards to cost, decreasing the time taken in dressing the wounds, healing rate, increasing the patient’s confidence, increasing the degree of healing and increasing the patients comfort. The hydrocolloid dressings were also more cost effective and environmentally better due to the lower frequency of dressing changes, requiring fewer materials to be used (Jones 2006, p 83). For patients, the hydrocolloid dressings could be considered a superior dressing in comparison to gauze, due to fewer traumas being caused to tissues, local pain relief, due to protection of nerve endings, better healing rate, and decreased time used to change dressings, resulting in less discomfort (Jones 2006, p 83).

3.6 Limitations and gaps:

Limitations present within this paper are things such as the use of only single blinding. Though single blinding may reduce a certain level of bias present within the research, it will not remove all bias. The authors were blind to the patients’ assignment to trial groups, and the general practitioners were blind to the treatment of each patient up to the start of the study. This will prevent a certain degree of bias. However, during the trial, after the intervention began, the nurses, patients and general practitioners were aware of the trial groups (Hollisaz et at. 2004, p 5). This made room for bias within the study, as they could subconsciously, or consciously, affect the patients’ reactions to particular treatments (Hollisaz et at. 2004, p 5).

Sample size could also be considered a limitation within this paper. The use of a smaller sample size of 83 patients could cause ‘sampling error’, due to the fact that there were not enough subjects used to obtain the best possible result (Carneiro 2011, pp 62-63). In future, the use of a smaller sample size could also prevent the study from adequately being generalized to the overall population (Carneiro 2011, pp 62-63).

3.7 Recommendations for further research:

In regards to future research, it would be wise to use a double blind technique. This is considered the ‘gold standard’ for randomised controlled trials (Carneiro 2011, p 127). Blinding of both participants and observers makes the study free from bias and influence of the participants, or observers, subconscious feelings towards a treatment (Carneiro 2011, p 127).

It would also be wise for the study to include a larger sample size. The use of a larger sample size will lead to an increase of the power and precision of studies, as well as making the study more adequate to be generalized to an overall population (Carneiro 2011, p 63).

4.0 Conclusion

The overall evaluation of five papers resulted in the conclusion that hydrocolloid dressings were favoured in the treatment of pressure ulcers, in comparison to simple gauze dressings. The papers reviewed were of varying evidence levels. The papers discussed were two systemic reviews, which presented with level I evidence, one randomised controlled trial, which presented with level II evidence, one cohort study, which presented with level III-II, and finally one journal article, which presented with level III-III evidence. These papers provided evidence to support their proposals that certain dressing were better than others in relation to pressure ulcer healing. However, these papers were critiqued, and the assessment provided a discussion of the quality of the research done, and the limitations which may have decreased the validity of the studies. All studies appeared to be statistically significant, and valid enough to demonstrate the benefits of using a hydrocolloid dressing, over a simple gauze dressing.