Introduction:
Chronic wound like pressure ulcers and neuropathic ulcers posed unique challenges for wound care professionals. To ensure that uniform policy exists regarding treating acute wounds in all setting, many evidenced based guidelines have been developed. These guidelines have played a role in reducing barriers for wound healing and promoting consistency in the documentation of wound care. Interdisciplinary communication is also enhanced by the development of wound care management guidelines (Ubbink et al., 2015). The main purpose of this paper is to critique two wound care management guidelines using the AGREE 11 tool and comparatively evaluate the strength and weakness of the two tools. The first tool that will be used in this paper include the ‘Guideline for the Assessment & Management of Wounds’ developed by NHS foundation trust for the Northamptonshire Trust. This guideline gives idea about measures that can be taken when normal wound healing fails (NHS Foundation Trust 2017). In addition, the second tool that will be analyzed include the ‘HSE National Wound Management Guidelines 2018’ developed for Irish health care setting. This guideline is an updated guideline that provides evidence based approach for wound care management (Wynne 2018).
Critique of the 2 clinical practice guideline using the AGREE 11 tool:
The critique of the tools and results obtained using the AGREE 11 tool has been provided in appendix.
Discussion on why one of the guideline is better than the other:
Based on the critique of the two wound care management guidelines, it can be said that the ‘HSE National Wound Management Guidelines 2018’ is better than the ‘Guideline for the Assessment & Management of Wounds’ because of completeness of information and consideration of all important information that is needed for application of evidence into practice. The discussion regarding the recommendations mentioned by each tool and the method of reporting can give idea regarding the difference in quality of both tools. The ‘Guideline for the Assessment & Management of Wounds’ will be defined as guideline 1 and the ‘HSE National Wound Management Guidelines 2018’ will be described as guideline 2 from this section.
While reviewing the reporting methods for both the guidelines, it can be said that guideline 2 provides complete information with information not just on the key recommendation but also on the method of developing the guideline. While critically appraising the guideline 1 using the AGREE tool, it has been found that the document lacks rigor of development. The purpose and scope section of the document mentions that the wound care management guidance is based on evidence based care principles. However, this information is not considered reliable because no information has been provided regarding the method adapted to search for evidence and critically evaluation them before framing it as a recommendation. Majid et al (2018) argues that while engaging in evidence based practice, it is necessary to adapt an appropriate search strategy and retrieve current and relevant evidence. Hence, presence of information related to search strategy and process used to critically evaluate research evidence would have increased the rigour and reliability of the guideline. The guideline 1 by NHS Foundation Trust (2017) has not reported about search strategy and this seriously impedes the reliability as well as the application of evidence. In contrast, the guideline 2 by Wynne (2018) gave information about the development of guidelines by giving explicit details related to the clinical question, literature search strategy, data extraction and data analysis technique and quality appraisal. Wynne (2018) also considered grading all the recommendation after developing grading scheme. This technique is commendable as it used the hierarchy of evidence types from which the information was sourced to grade the recommendation. Hierarchical system of classifying evidence is the cornerstone of evidence based medicine and understanding the level of evidence can help to interpret and prioritize information (Burns, Rohrich and Chung 2011).
Another major difference between the protocol is the clarity of presentation. The recommendations proposed is the most vital component of the two wound management guidelines and the quality of presentation can determine whether it is useful for the target setting or not. In terms of presentation of content, it can be said that there is stark difference between the two guidelines. For example, the presentation of recommendation by Wynne (2018) is very focused and relevant to the main challenges faced during wound management in clinical setting. For example, burden of care increase due to hospitalization for non-healing wounds like surgical wound, pressure ulcers and foot ulcers. Hence, those guideline would be useful that categorise different types of wound and then suggest specific advice for clinical practice. Accordingly, guideline 2 by Wynne (2018) considered different wound management situation and classified the recommendation by discussing about general wound care, diabetic foot ulcers, pressure ulcers, leg ulcer and palliatiave wound care separately. For each area, recommendation was proposed for risk assessment, assessment tool and recommendation. Compared to guideline 2, guideline 1 by NHS Foundation Trust (2017) has very ambiguous information related to wound care management. This is because it defines the process of wound healing, documentation of wound care and different dressing types but not separate process for management of different wounds. This is a major limitation of the guideline as health care professionals would not be able to apply the guidelines in clinical practice. It does not present any systematic recommendations such as type of risk assessment and management process needed for different types of wound. Hence, this justified why guideline 1 is inferior to guideline 2 in terms of quality and content of the presentation. The purpose of developing clinical guideline is defeated due to lack of clarity in presentation and poor relevance of the guideline in the context of real practice (Ya?ar et al. 2016).
Shekelle et al. (2012) suggest that while developing any clinical practice guideline, it is important to develop strategies to increase uptake of the guideline. For example, this would be possible by taking steps to identify potential barriers of recommendation, using specific language, identification of resource implication and use of data collection tool. Similar type of technique has been considered by Wynne (2018) for developing the guideline too. For example, guideline 2 covered all details regarding potential barriers for each recommendation. In addition, the overall facilitators to the implementation of the guideline were also identified. The clarity in reporting about barrier and facilitators is also understood from the fact that the developer also reported about strategies to address the barrier and defining facilitators that would improve uptake of the guideline. Throughout the reporting about recommendations for wound care, resource implication was discussed too. In contrast, tool 1 by NHS Foundation Trust (2017) also identified barriers to the application of the evidence. However, resource implication and specific training needs were missing. For this reason, guideline 2 is considered better than guideline 1. Fischer et al. (2016) also supports the fact the success of the implementation of guidelines is dependent on the consideration of barriers and strategies to address them. This can promote adherence to the guideline and development of strategies tailored to the specific health setting.
On comparison of the two wound care management guideline, another difference has been found in the reporting about stakeholder involvement. According to Massoni, Ricci and Ricci (2014), review of stakeholder involvement is necessary in evidence based medicine as this has an impact on the formulation of the recommendation and operational applicability of the evidence. The guideline 1 gave no details about stakeholder involvement and guideline 2 gave all details related to types of stakeholders involved and approach taken to critically appraise the recommendations identified from different research papers related to wound care. Hence, as no details have been provided regarding stakeholder involvement, it has affected the quality of recommendation and direct application of the guideline in clinical practice too. In contrast, the guideline presented by Wynne (2018) is very reliable because of transparent reporting and it can be easily applied in clinical setting.
Possible reasons for difference in the quality of the two tools:
The above discussion on the quality of the two selected wound management guidelines reveals several differences in the quality of the protocol. Such differences might have occurred because of lack of engagement of appropriate stakeholders during the development of tool 1. This can be said because both the guidelines were backed by renowned agencies like HSE and the NHS, but still the desired level of recommendation was not found for guideline 1. This could be explained by lack of involvement of experienced stakeholders from the field of wound care and management while developing guideline 1. In contrast, guideline 1 was framed based on the clinical judgment and decision making done by stakeholders from relevant field of interest. The quality of the guideline 1 might have been compromised because of personal factors like lack of agreement and efficacy of the key stakeholders too. Individualized audit and feedback was also not done which might have affected the quality of the guideline.
Conclusion:
The report summarized the results obtained based on the critical appraisal of two wound care management guidelines using the AGREE tool. The AGREE tool evaluated the two guideline based on the elements like scope and purpose, stakeholder involvement, rigor of development, clarity of presentation and applicability of the evidence. The overall conclusion from the critical appraisal is that guideline 2 (HSE National Wound Management Guidelines 2018’ is better than guideline 1 (NHS Foundation Trust 2017). The main rationale behind this is that guideline 2 addressed all elements that were needed for increasing the reliability of the recommendation, promoting transparency in reporting and enhancing the credibility of the information. The reporting process was complete with detailed information about search strategy, critical appraisal and grading of evidence, barriers to research application and resource implication. In addition, wound care management recommendation was clearly specified by categorizing types of wound care in guideline 2. However, guideline 1 could not be directly applied for evidence based practice before of presence ambiguous information and many missing information. It is recommended to follow the principles of evidence based practice while developing clinical practice guidelines and consider factors to promote transparency of the evidence.
References:
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Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y.L., Chang, Y.K. and Mokhtar, I.A., 2011. Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers. Journal of the Medical Library Association: JMLA, 99(3), p.229.
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NHS Foundation Trust 2017. Guidelines for the assessment & management of wounds. Retrieved from: https://www.nhft.nhs.uk/download.cfm?doc=docm93jijm4n1793.pdf&ver=17402
Shekelle, P., Woolf, S., Grimshaw, J.M., Schünemann, H.J. and Eccles, M.P., 2012. Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implementation Science, 7(1), p.62.
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