Speaking in 2012, Dr Karen Ousey discusses tissue viability research

We talk a lot about research in tissue viability and we also talk about the hierarchy of evidence. So you will have probably seen a pyramid that has randomized controlled trials at the top and people's viewpoints at the bottom and that's how we tend to grade the evidence that we use. Notoriously it's quite difficult I think Trudy to be able to do randomized controlled trials or RCTs in wound care and tissue viability because you never get two groups of people that have the same comorbidities, that are the same age, that have both got diabetes for example, both got rheumatoid arthritis, with exactly the same wound in the same place and the same depth. So we can't do like for like, but there are some randomised controlled trials around that are really, really good and people do need to look at them. And particularly a good way to find them is to look at Cochrane, and Cochrane undertake lots of different reviews on things to do with negative pressure wound therapy, quality of life, leg ulcer management, compression and they've generally identified all the randomised control trials so you're able to access them through looking at Cochrane. But we've also got to look at evidence and look at case studies that people undertake in wound care as well because we've got lots and lots of really good practitioners out there who will write case studies about a certain wound dressing or a type of compression that they've used on a wound and the outcome's been really good and people will often say well a case study is not very good it's only one patient but if we look at all the case studies we've got and we'll probably then have maybe a hundred case studies that different people have done using the same product on very similar wounds with the same dressing then we can probably assume that that evidence actually is quite reliable and we can use that as well. So there's lots of different types of research and evidence around and it's up to the practitioners to make sure they're up to date with what's going on as well in wound care. So not just looking at research and what supports the interventions we're doing, we've got to understand the theory as well underpinning what we undertake. So in my viewpoint I think that we've got everybody has to understand why they put a certain dressing for example onto a wound, but what's in that wound dressing, how is it working with the wound, how is it interacting with the wound and what's the four stages of wound healing so you can understand what's happening and then you're able to link the research and the evidence to your practice and make people safe and effective practitioners. So if you look at best practice documents it has been written by a team of experts in wound care tissue viability leg ulcers or management of skin integrity who are able to read the evidence, discuss interventions they've done in the past and how they've worked, bring all that evidence together and and then write in a best practice document that tells the practitioner, or suggests to the practitioner if they see a certain type of wound, this is what will work best based on the evidence. The consensus document, very similar, and that's a team of people together that have been looking at a problem and then they'll find solutions and the whole team will agree to what the best solution is. So even though they're not research, by nature of what they call best practice, It does ensure that we're delivering safe and effective care that is underpinned by the best research and the best evidence that we know at this point in time. There's all this different evidence out there and people look and suddenly they think, right, we know what we're doing. Then they open up some guidelines and think, oh, now there's three different sets of evidence, which is the best. But you've got to remember that guidelines are what they say, they're only guidance. So it's not what you should be doing, it's the guiding you towards best practice. So the evidence is there to say, stage one evidence, for example, will be randomised control trials and will be really good, solid, quantitative research. You'll then go down a couple of stages and that might be what people are saying, things that they've seen work and it's anecdotal practice really, so they know what's going on. But as I was saying, guidelines are guidance, so you need to look at each of those evidence stages and think right my patient requires compression on so if I look at this the best practice tells me that I need to use four layer and that's grade one so that's good but it might also say that the patient complains of pain you may want to reduce your compression and then that might say that actually that's stage three evidence but you've got to look at what your patient's saying so it's very much individual and it's for the practitioner as well to use their knowledge, remember these are only aid memoirs as well, to best practice. Any sort of literature you read says RCT is the gold standard and expert opinion isn't the gold standard, it's probably the bronze standard if we're looking at gold, silver and bronze. However I think we've got to be really careful in tissue viability because like we said at the beginning, you never get two patients exactly the same with the same wounds. So I think expert opinion is very relevant in tissue viability. There's lots of experts around who have got years of experience and practice and undertaking research in different forms, maybe not RCTs but they've done different sorts of studies, they've done experimental studies, they've done in vitro studies, they've done maybe cohort studies where you get groups of patients together and ask them what the patient thinks. So all that together gives us an excellent research and evidence base. So in a nutshell I would say that within tissue viability we've got to look at all forms of evidence and research as being good and we can't just say that one is gold standard because our patients are far too different than they are in other areas where you can just compare like for like. If we look at maybe in vitro studies for wound care, so we're looking at laboratory based experiments and research, then yes, your randomised control trials won't be gold standard there because you can have like for like. But in In the real world, we've got to look at what we've got and look at it properly, research what we've got and then join it together and look at the best practice statements, look at the consensus statements, look at the case studies as well as looking at the RCTs that are there.