Effectiveness of interventions to enhance shared decision making in wound care: A systematic review

Aims: To explore the effectiveness of interventions to enhance patient participation in shared decision making in wound care and tissue viabilityBackground: Caring for people living with a wound is complex due to interaction between wound healing, symptoms, psychological wellbeing, and treatment effectiveness. To respond to this complexity, there has been recent emphasis on the importance of delivering patient centred wound care and shared decision making to personalise health care. However, little is known about the effectiveness of existing interventions to support shared decision making in wound care.Design: Systematic review of interventional studies to enhance shared decision making in wound care or tissue viability. This was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020.Methods: Interventional primary research studies published in English up to January 2023 were included. Screening, data extraction and quality appraisal were undertaken independently by two authors.Data sources: Medline, EMBASE, Cochrane Central Register of Controlled Trails (trials database), CINAHL, British Nursing Index (BNI), WorldCat (thesis database), Scopus and registries of ongoing studies (ISRCTN registry and clinicaltrials.gov).Results: 1,063 abstracts were screened, and eight full-text studies included. Findings indicate, interventions to support shared decision making are positively received. Goal or need setting components may assist knowledge transfer between patient and clinician, and could lower short term decisional conflict. However, generally findings within this study had very low certainty due to the inconsistencies in outcomes reported, and the variation and complexity of single and multiple interventions used.Conclusions: Future research on shared decision making interventions in wound care should include the involvement of stakeholders and programme theory to underpin the interventions developed to consider the complexity of interventions.Registration: The review protocol was prospectively registered (PROSPERO database: CRD42023389820).No Patient or Public Contribution: Not applicable as this is a systematic review

Palliative wound care: optimising the use of classification systems

Systemy klasyfikacyjne stanowią użyteczne narzędzie pozwalające na sprowadzenie złożonego stanu/choroby do możliwych do określenia elementów oraz ułatwiające komunikację pomiędzy profesjonalistami. Systemy te mogą służyć do definiowania, zazwyczaj w aspekcie nasilenia, poszczególnych objawów chorób i stanów. Mogą również być stosowane przy klasyfikowaniu predyspozycji do pewnych stanów, np. ryzyka powstania odleżyny. Uzyskane informacje wykorzystuje się przy planowaniu leczenia i opieki oraz do prognozowania przebiegu. Systemy klasyfikacyjne mogą być obszerne i złożone, jeśli dotyczą złożonych procesów lub stanów chorobowych, lub mogą być uproszczone. Oba te ograniczenia są szczególnie istotne w medycynie paliatywnej, w której poważny stan pacjentów wiąże się z współwystępowaniem licznych schorzeń i wymaga stosowania wielu metod leczenia oraz uwzględnienia indywidualnych cech chorego. Skuteczne stosowanie systemów klasyfikacyjnych przy podejmowaniu decyzji klinicznych wymaga, oprócz rozległej wiedzy klinicznej, stosowania obowiązujących i praktycznych systemów. System kliniczny TELER®, oparty na sporządzaniu notatek, jest nowoczesnym sposobem oceny, łączącym w sobie klasyfikację, planowanie opieki oraz ocenę wyników leczenia. System ten uwzględnia cele pacjenta, wiedzę teoretyczną i kliniczną oraz w unikalny sposób ocenia, jak zmieniają się dolegliwości pacjenta pod wpływem leczenia i pielęgnacji. Do tego systemu można włączyć uznane systemy klasyfikacyjne, np. drabinę analgetyczną Światowej Organizacji Zdrowia, stosowaną przy łagodzeniu bólu nowotworowego. Niniejsza praca przedstawia system TELER® jako narzędzie wykorzystywane przy podejmowaniu decyzji i szczegółowej ocenie leczenia paliatywnego ran, w kontekście całościowej opieki nad chorym.Classification systems can be useful tools for reducing a complex disease/condition into identifiable elements, and a means to communicate these between professionals. These systems may be used to define, usually in terms of severity, specific aspects of diseases and conditions. They may also be used to classify predisposition to specific conditions, for example the risk of pressure ulceration. Information generated is used to guide treatment and care planning, and to predict outcomes. Classification systems can become lengthy and complicated in the process of trying to represent the complex disease process/condition, or they are a simplification. Both these limitations may be particularly important in the specialty of palliative care where the advanced nature of patients’ conditions often results in multiple overlapping disease, treatment and individual variables. The successful use of classification systems in clinical decision-making requires valid and practical systems to be used alongside sound clinical knowledge. A novel approach that combines classification, care planning and treatment evaluation is a clinical note-making system, TELER®. This system includes patients’ goals, theoretical and clinical knowledge, and uniquely measures how patients’ problems change with treatment and care. The system can incorporate validated classification systems, for example the World Health Organisation analgesic ladder for cancer pain relief. In this paper the system is presented as a tool that has been applied to decision-making and evaluation in relation to the discrete elements of palliating wounds, in the context of total patient care

Translating patient needs into medical device development: co-design of a photoprotection visor for Xeroderma Pigmentosum using qualitative interviews

Introduction: People with Xeroderma Pigmentosum (XP) have a heightened sensitivity to ultraviolet radiation (UVR) and are advised to wear photoprotective clothing including a visor covering the face and neck. Photoprotective visors are homemade and predominately worn by children with decreasing frequency as age increases. To improve upon the current design and efficacy we were tasked with developing a prototype visor to meet patients’ needs. Methods: Adopting a codesign methodology, patients’ experiences of wearing a visor and patient and carer views of emerging prototypes were explored during interviews. A thematic analysis was conducted in parallel with data collection and themes were interpreted into design cues; desirable attributes of a visor that would counteract the negative user experiences and meet the requirements described by patients and carers. The design cues guided the iterative development of prototypes by academic engineers. Results: Twenty-four interviews were conducted with patients and carers. Thematic analysis resulted in the following five themes: Being safe from UVR exposure; self-consciousness; temperature effects; acoustic difficulties; and material properties. The following design cues were developed from the themes respectively; materials and design with high UVR protection; ability to customise with own headwear; ventilation to reduce steaming up; acoustic functionality to enable hearing and speech; foldable, portable, and easy to put on and take off. Conclusions: It is important to understand people’s experiences of using medical devices to improve their safety, efficiency and user satisfaction. The user experience themes and design cues, informed the iterative development of low fidelity visor prototypes as part of a codesign process. These design cues and responses to the prototypes are guiding commercial manufacturing and regulatory approval. The visor can then be prescribed to patients, providing an equitable service of care

Electrochemotherapy for the palliative management of cutaneous metastases: A systematic review and meta-analysis.

BACKGROUND: Electrochemotherapy combines electroporation in conjunction with chemotherapeutic agents and is used to treat tumours in many localisations, including cutaneous metastases. The symptoms associated with cutaneous malignant wounds can be distressing for patients and their management is a challenge in healthcare. AIM: The purpose of this systematic review was to investigate the effectiveness of electrochemotherapy in the context of palliative care. DESIGN: All aspects of the systematic review were followed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES: The following databases were searched for English-language reviews; Medline, Embase, CINAHL, British Nursing Index and the Cochrane Library. The search was conducted between the publication of Standard Operating Procedures in 2006 and the third week of October 2017. Studies involving oral cancers and studies with fewer than 10 patients were excluded. The selected studies were assessed for risk of bias and sub-group data were synthesised in a random-effects meta-analysis. RESULTS: From 425 studies, 29 studies were included involving 1503 patients, the pooled results were 46.6% for complete response and 82.2% for objective response according to the Response Evaluation Criteria in Solid Tumours. The meta-analysis indicated that small tumours were over twice as likely (2.25) to have a complete response than large. CONCLUSIONS: Electrochemotherapy is an effective, repeatable and minimally invasive intervention within the palliative population that can reduce symptom burden. This review is an update of previous systematic reviews by Mali et al. [1,2] and highlights the need for tailored treatment depending on each individual case

Using experience-based co-design with older patients, their families and staff to improve palliative care experiences in the emergency department: a reflective critique on the process and outcomes

Background: Increasing use of emergency departments among older patients with palliative needs has led to the development of several service-level interventions intended to improve care quality. There is little evidence of patient and family involvement in developmental processes, and little is known about the experiences of − and preferences for − palliative care delivery in this setting. Participatory action research seeking to enable collaborative working between patients and staff should enhance the impact of local quality improvement work but has not been widely implemented in such a complex setting. Objectives: To critique the feasibility of this methodology as a quality improvement intervention in complex healthcare settings, laying a foundation for future work. Setting: an Emergency Department in a large teaching hospital in the United Kingdom. Methods: Experience-based Co-design incorporating: 150 hours of nonparticipant observation; semi-structured interviews with 15 staff members about their experiences of palliative care delivery; 5 focus groups with 64 staff members to explore challenges in delivering palliative care; 10 filmed semi-structured interviews with palliative care patients or their family members; a co-design event involving staff, patients and family members. Findings: the study successfully identified quality improvement priorities leading to changes in Emergency Department-palliative care processes. Further outputs were the creation of a patient-family-staff experience training DVD to encourage reflective discussion and the identification and application of generic design principles for improving palliative care in the Emergency Department. There were benefits and challenges associated with using Experience-based Co-design in this setting. Benefits included the flexibility of the approach, the high levels of engagement and responsiveness of patients, families and staff, and the impact of using filmed narrative interviews to enhance the ‘voice' of seldom heard patients and families. Challenges included high levels of staff turnover during the 19 month project, significant time constraints in the Emergency Department and the ability of older patients and their families to fully participate in the co-design process. Conclusion: Experience-based Co-design is a useful approach for encouraging collaborative working between vulnerable patients, family and staff in complex healthcare environments. The flexibility of the approach allows the specific needs of participants to be accounted for, enabling fuller engagement with those who typically may not be invited to contribute to quality improvement work. Recommendations for future studies in this and similar settings include testing the ‘accelerated' form of the approach and experimenting with alternative ways of increasing involvement of patients/families in the co-design phase

A methodology for evaluating wound care products in complex chronic wounds

The question of whether particular methodologies can generate knowledge of a sufficiently rigorous and relevant standard to guide patients’ interventions is regularly debated. This debate tends to be polarised between those who advocate the randomised controlled trial (RCT) as the ultimate scientific methodology and those who find RCTs wanting in terms of the information derived and their limited generalisability beyond the immediate trial population. This paper argues for a suite of methodologies that can evaluate wound care interventions; it also details a novel methodology for use in complex chronic and palliative wound care.Aim: To outline a methodology that can evaluate the clinical performance of wound care products in the context of complex treatment and care.Methods: The methodology is informed by the UK Medical Research Council framework for the design of complex evaluations, and is an N-of-1 design.Results: A novel methodology for evaluating the effectiveness of wound care technologies in complex chronic wound care and palliative wound care has been proposed.Conclusion: The methodology requires validation in prospective studies. The purpose of this paper is to open a constructive debate