Student care is that “convincing information leads to

Student Profile:

The author is a registered
general nurse in the adult area with the Nursing and Midwifery Council of the
United Kingdom since 2003. She has worked for the Ulster Hospital of the South
Eastern Health and Social Care Trust as a staff nurse in the Acute Trauma
Fractures Ward from 27 August 2002 until 18 May 2015 following successful
application as a community staff nurse with the Belfast Health and Social Care
Trust. She is a  member of the Dundonald
Integrated Care Team based at The Arches Centre in East belfast. She is enrolled
in Bachelor of Science (Hons) in Nursing with Specialist Practice in District
Nursing and Integrated Nurse Prescribing at the University of Ulster school
year 2017-18. The Evidence and Research Underpinning Nursing Practice is a core
module in the Specialist Practice. Evidence-based practice is an approach that
goes beyond simply providing care that is in line with the current research
findings. It is about incorporating the best available research alongside
consideration of clinical expertise, patient choice and health care costs
(Dickersin et al., 2007). The underpinning hypothesis of such evidence-based
care is that “convincing information leads to optimal decision making” (Grol,
2001). Therefore, in the district nursing practice, delivery of person-centred
care should be aimed at effective and compassionate care based on best
available evidence.

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This article will aim to answer
the research question:  How effective is
hydrogel dressing in the treatment of venous leg ulcers of older persons in the
community? Questions are the driving force behind evidence-based practice. If
there were no questions to issues, evidence-based practice is unnecessary
(Eldredge, 2000).  This research question
is based on the PICOT  model to enhance
the search and identify and explore literatures with relevance to the topic (Melnyk,
B.M. & Fineout-Overholt, E. 2005). The PICOT format is a helpful approach
for summarising research questions that explore the effect of a therapy:

(P) – Population/patients/problems
– refers to the sample of subjects you wish to study.

(I) – Intervention refers to the event
or treatment on your subjects that you need to study the effect of.

(C) – Comparison identifies what evidence
the event or treatment results in than a different or no intervention at all.
Most study methods refer to this as the control group.

 (O) – Outcome is the result of the intervention
that you plan to compare or measure effectiveness as well as identify strengths
and weaknesses.

 (T) – Time describes the period of the data

As a community staff nurse, the
management of venous leg ulcer is a daunting and challenging experience due to
the increase in referral and long term care of persons with leg ulcers often
requiring lengthy visits and nearly all with compression bandaging and advanced
wound dressings over ulcer beds. The personal experience from the lack of clear
guidelines within the team, unique patient needs and limited professional
knowledge have at times proved confusing. The author had developed particular
interest in the use of actiformcool dressing, a type of hydrogel dressing in
the management of venous leg ulcer. As a product user and would-be nurse
prescriber , she would like to search for further evidence to support her
future practice and share valuable information obtained to colleagues and

A background on the context of
venous leg ulcer and relevant sources will be discussed which will support the
aims and objectives of the essay. This information is essential in
understanding that chronic wounds is an important health problem not only in
the United Kingdom but internationally. The methodological processes will
outline the keywords and search for relevant literatures with the view of
critically evaluating evidence,  discuss
their significance and make recommendations to the district nursing practice.


Venous leg ulcer in context

Venous leg ulcer is the most
common chronic wound affecting one-in-500 people in the United Kingdom
(increasing to one-in-50 in those aged over 80) and takes about four to six
weeks to heal (Scottish Intercollegiate Guideline Network (SIGN), 2010). ). The
increasing prevalence of venous leg ulcer is coinciding with the
increasing  older population in the
United Kingdom and considered an important health problem that not only impacts
on a persons’ wellbeing but  also incurs
significant financial costs. Although mainly older people are affected, people
at any age can develop venous leg ulcer (Kantor and Margolis, 2007). In a well
known study by Guest et al (2015) set out to understand the size and cost of
wound care to the National Health Service (NHS), the authors estimated that in
2012-13 there were 2.2 million patients with wounds, requiring around thirty
million nursing visits and cost the NHS £4.5-5.1 billion and two thirds of this
cost is incurred in the community.  In
the United States of America, venous leg ulcers have been estimated to affect
between 0.2% and 1% of the toal population and between 1% to 3% of the elderly
population and Europe (Margolis 2002). The estimated incidence of venous leg
ulcers in the older population aged 65 years and older per 100 person-years is
around 0.76 for males and 1.42 for females (Margolis 2002).  The estimated prevalence of venous leg ulcers
ranges between 0.6 and 1.9 per cent in the adult population of the United
Kingdom, United States of America and Europe (Briggs 2003).

A venous leg ulcer (VLU) is the
result of venous insufficiency associated with venous hypertension.  A VLU is an open wound on the ankle or lower
leg of venous origin (WOCN, 2011). The symptoms of a venous leg ulcer include
pain, itching and swelling in the affected leg. There may also be discoloured
or hardened skin around the ulcer, and the sore may produce a foul-smelling exudate
when fluid leaks and damage the patient’s skin. (Simon et al, 2004; NHS
Choices, 2012). Older persons with venous leg
ulcer most often present with repeated cylces of ulceration, healing, and
recurrence. There is an 18%-28% estimate of recurrence rates within a year for
this patient group that an  ongoing
management and prevention of recurrence should be treated as a priority (Ashby,
et al, 2014). According to the Royal College of Nursing clinical practice
guidelines (RCN, 2006), successful leg ulcer management requires a holistic
assessment to be able to properly identify the underlying cause and effective
treatment.  Usually, the first point of
contact for patients in the community is a member of the nursing team. The
assessment of the peripheral perfusion of the leg is the fundamental
requirement for management. In the  United Kingdom, it was evaluated that only 16%
of all cases of leg ulcer had a Doppler ankle brachial pressure index (ABPI)
recorded (Guest et al 2015). The ABPI assessment is not for the district nurse
practitioner to diagnose a venous disease but to confirm safe practice through
compression treatment.  An ABPI result
within 0.8-1.3, an area of less than 100 centimetres squared and present for
less than six months indicates a simple venous leg ulcer and should be managed
in the community by staff competent in administering compression therapy
(Harding et al 2015). A complex venous leg ulcer has the following results and
characteristics: ABPI outside of 0.8-1.3 range, area above 100 centimetre
squared, present for more than six months, controlled/uncontrolled cardiac
failure, current infection and/or history of recurrent infections, history of
non-concordance with treatment, wound has failed to reduce in size by 20-30% at
4-6 weeks despite best practice, fixed ankle or reduce range of motion, foot
deformity and unmanaged pain(Harding et al 2015). Building a therapeutic
relationship with persons with venous leg ulcer is a practice that each member
of the nursing tram need to adhere as per the Nursing and Midwifery Code of
Practice in 2015. Consequently, the aim to promote compliance to treatment and
care has to be delicately balanced in respect to the person’s autonomy and
preferences. The challenge to provide high quality of care while working
towards cost-effective treatment is one of the challenges that every community
staff is faced with. Delivery of an effective nursing care requires knowledge
in understanding the pathophysiology of venous insufficiency, control factors
that affect healing and the use of appropriate dressings and healing products
(WOCN 2011).


Clinical Relevance of Advanced Wound
Dressings to Venous Leg Ulcer

Multi-layer compression bandaging
has been identified as the gold standard in the treatment of venous leg ulcers.
Wound dressings are usually placed over the ulcer before compression bandages
or hosiery are applied, with the aim of optimal healing and prevent the
bandages from adhering to the wound. Research studies conducted the past twenty
years have recommended that a moist wound environment is essential for wound
healing. There is an overwhelming proliferation of advanced wound dressings in
the market since a systematic review of dresings for venous leg ulcer was
published and has left the nurse prescriber confused about when it is
appropriate to use these dressings(Bradley et all, 1999). It is essential that
practitioners have adequate training and expertise in wound management (Agency
for Health  Care Research and Quality 2014,
NICE 2016). Commonly used advanced wound dressings are the following:

Alginate dressings, which are highly absorbent.
They form a gel when in contact with the wound surface, and could be removed by
simply lifting off or rinsed away with sterile saline. A viscose pad applied
over alginate dressing helps increase absorbency.

Film dressings, which are permeable to water
vapour and oxygen but not to water or microorganisms.

Foam dressings normally contain hydrophyllic
polyurethane foam. They are designed to absorb wound exudate and maintain a moist
wound environment. Some foam dresssings include additional absorbent materials,
whereas others are silicone-coated for non-traumatic removal

Charcoal dressings, for treatment of malodourous
and infected wound

Honey dresssings, is derived from Manuka honey
and has antimicrobial and debridement property.

Iodine dressings, are non-adherent and
disinfectant containing dressing for surgical or infected wounds

Silicon dressings, are coated with soft silicone
as an adherent or wound contact dressing but do not cause trauma to wound or
surrounding tissue on removal.

Silver dressing, are for established wound
infection and for excesive wound bioburden.

Hydrocolloid dressings are made of
carboxymethylcellulose, gelatin, and pectins. They have semi-occlusive effect
and semi-permeable.

Hydrogel dressings, which consist of
cross-linked insoluble polymers and up to 96% water. They are designed to
absorb wound exudate or to rehydrate a wound, depending on wound moisture
levels (Jull et al 2015)

Search Strategy

A computerised search strategy
identified five databases: RCN Library (Summons), CINAHL plus, USearch, Google
Scholar and Ovid MEDLINE from 2012 to November 2017. The searched terms used
were, ‘leg ulcers’, ‘chronic wounds’, ‘Hydrogel dressing’ and ‘community
nursing’. The initial search generated 8,869 citations in total; 8,457 from
CINAHL Plus, 9 from Usearch, 312 from Ovid MEDLINE,  261 from RCN and 170 from Google Scholar (See
Appendix 1) . It is essential to determine an inclusion and exclusion criteria
before initiating search in order to retrieve relevant articles to answer the
research questions (Bettany-Salkikov 2012). All titles, introductions,
abstracts and conclusion were reviewed to meet the inclusion criteria, which
had to be 1. A published scientific article within the last five years, 2.
Written in English, 3. Empirical study,and  4. Describe Hydrogel Dressing (or its generic
name) treatment for leg ulcer or chronic wounds. Following this, only four
articles were selected and considered for analysis.

Critical Appraisal

A literature review is an
objective and thorough summary and critical analysis of the relevant, available
research and non-research literature on the topic being studied (Hart, 1998).
Analysing the literature is a structured process in order to determine strengths
and limitations of the chosen article(Aveyard, 2010) and a consideration to the
effectiveness of hydrogel dresssing to venous leg ulcer according to the
evidence base. On the appraisals made, the rigour of the process was managed by
the CASP (critical appraisal skills programme 2017). During the review process,
the following overlapping themes in all literatures were identified: study
population, Comparison to other advanced wound dressings, efficiency, and the proliferation
of advance wound dressings in the health care environment.


Safety and Efficiency

Of the four articles chosen for
analysis, three were systematic review of research, of which two are from the
United States of America and one from the United Kingdom. The other is a
clinical experiment on hydrogel products conducted in Germany. These articles
support the premise that a moist wound environment is essential for wound
healing, facilitating autolytic debridement while protecting peri-wound tissues
and minimising pain before, during and after dressing changes. Hydrogel as one
of the advanced wound dressings was evaluated through the study design of
randomnised controlled trials (RCTs) which is considered the hallmark of
evidence-based medicine and form the basis for translating research datas into
clinical practice (Spieth et al, 2016). Understanding the wound healing
process, the wound dressing components, and an ability to recognise the
continually changing needs of the venous leg ulcer helped the clinicians select
the appropriate dressings.

On the first comparative summary
of review of fifteen randomised controlled trials, the benefits of hydrogel
dressings to chronic wound was insufficient such that the designated
investigators were not able to draw conclusion as to its adverse effect or
benefits. The second comparative review, one of the studies compared hydrogel
with gauze soaked in povidone-iodine solution, in a study of 27 patients with a
total of 49 chronic wound ulcer. The number of wounds that healed in the two
groups was 84% with hydrogel versus 54% with gauze and was statistically significant
(p<0.04). There was no discussion as to the primary outcomes over the four week length of time the trial was conducted. The authors of the study concluded that hydrogel dressing facilitated healing by promoting rapid epithelialisation. The third systematic review of twelve randomised trials and 1,023 subjects found no differences among primary advanced wound dressings when applied beneath compression bandagings. The fourth study was an original study on the use of hydrogel on leg ulcers of 75 randomised controlled trial chosen from day zero to fourteenth day of treatment. The results showed that there had been >50% wound coverage with granulation tissue with hydrogel treatment on the
fourteenth day. In this study, seven patients had adverse events related to the
treatment: maceration=3, eczema =2, malaise=1 and device intolerance=1. There
was no data to show total wound healing for the 75 subjects.

In general, there is an uncertainty
as to the estimated effects all the dressings for the studies conducted and
lacking in quality to have a positive impact on the clinical practice.


Comparison to other Advanced Wound Dressings

After careful review of the
literatures on hydrogel dressings, although wound state information were
provided, the results were conflicting. None of the trials clearly demonstrated
superiority of materials or categories of one advanced wound dressing to the
other. Cost effectiveness of any of the advanced wound dressings were not
discussed in the lietrature except that they entail high financial cost.

Protocols and Guidelines

It is clear that a consensus
exist that clicnical practice in wound care should be evidence based,
difficulty arises due to confusion about the various approaches to wound management.
In the United Kingdom,  the review summary
referred to the Scottish Intercollegiate Guidelines Network (SIGN) published  guidance in 2010 on the management of chronic
venous leg ulcers that had been accredited by the National Institute of
Clinical Excellence (NICE 2016) stated that simple non-adherent dressings and multi-layered
compression bandaging is the treatment of choice for venous leg ulcers.
Graduated compression hosiery is recommended to prevent recurrence of venous
leg ulcers. In Europe, in an effort to address the challenge on wound
management, the European Wound Management Association had set up a Patient
Outcome Group to produce recommnedations on clinical data and collectionon
wound care (Gottrup et al 2010).

Advanced Wound Dressings and the Health Care System

The common observation of all the
authors that the is a proliferation of advance wound dressing in the the market
and this is still ongoing following studies over the years that a moist wound
environment is essential for wound healing. This author agrees that all the
studies were aimed at informing prescribers and other practitioners of the
evidence available about advance wound dressings. It is worth noting that the
the Cochrane Wounds Group has collaborated with researchers from Brazil led by
Cibele TD Ribeiro to conduct intervention protocol for systematic review on
hydrogel dressings for venous leg ulcers in 2013. The outcome of the systematic
review of this collaboration will highly likely give specific evidence to the
clinical practice of health care professionals across the health care
environment especially to the primary health setting where long term conditions
are being managed