Lower Limb Assessment Poster Cawc
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John Gregory http://myiiwccselective.blogspot.com
A Blog as an Enabler for Practice for Lower Limb Assessment Purpose:
D
emystifying Ankle Brachial pressure Index (ABI) assessment through the dissemination of interactive enablers was chosen as a selective for the International Interprofessional Wound Care Course (IIWCC) through the University of Toronto. The need for a simple tool to enable wound care practitioners to confidently conduct ABIs was identified. The aim of the work was to make audio and video resources more widely available to healthcare professionals in one easy to access central location, through a blog as an educational enabler.
The need for vascular assessment: Kevin Woo et al stated in a 2007 audit of leg and foot ulcer care in Ontario that approximately 30% of the clients in both Toronto (29%) and Peel (32.7%) who received community care for ulcerations did so without a diagnosis of the ulcer 1 etiology in their records . Similar percentages were receiving high compression using multi-layer bandaging systems. As well the majority of subjects had not undergone any known special vascular testing (Peel 48.1% and Toronto 58.6%). Christine Moffat & Peter Franks report a high proportion of patients with unspecified ulcer etiology, noting that the level of assessment was poor suggesting that the etiology of ulceration was unproven in most cases2. There are poor implementation protocols despite the availability of best practice guidelines or recommendations developed by the Registered Nurses’ of Ontario (RNAO) and CanadianAssociation of Wound Care (CAWC)3,4. The literature consistently recommends a complete diagnostic assessment for patients with lower extremity ulcers including an Ankle Brachial Pressure Index (ABI) to detect arterial disease. ABI can be relatively inexpensive and easily assessed with a hand-held Doppler. There are a number of simple enablers which help clinical staff cross-reference the ankle and brachial pressures to indicate the pressure index. Whilst the technique is fairly easy and very well documentedin the literature it is not one with which many healthcare professionals are familiar or use regularly. There appears to be a gap in the literature on enablers for conducting ABI examinations. Enablers currently e xist but they are company sponsored and are not cited in the literature. A wider distribution of enablers needs to be made available to assist with the wider implementation of ABI examinations.
Literature review of ABI: Literature searches were conducted through a number of sources. 1) Huntleigh Diagnostics in Cardiff 2) Opinion leaders in the field 3) Best Practice Guidelines/ Recommendations & Consensus Documents 4) Online research 5) WoundPedia Huntleigh Diagnostics were willing to share their library of papers on diagnostic ultrasound relating to ABI,
“The most rewarding research is the one that delights the thinker and at the same time is beneficial to humankind.”
which included original papers, recommended literature and international best practice recommendations. A selection of authors and educators in the field of vascular assessment and leg ulceration were consulted in order to gain further guidance and literature/best practice recommendations. Copies of identified papers/guidelines were obtained and reviewed. Finally, research was conducted through online search engines including MedLine, PubMed, Google Scholar and the Cochrane Database. The literature was not weighted through the AGREE instrument or critically appraised. WoundPedia (www.woundpedia.com) is a wonderful new wound care resource launched at the World Union of Wound Healing Societies 2008. It includes a systematic review by Mario Caruana et al which includes significant information about ABI and its value in 5 evaluating people with venous leg ulcers and asymptomatic peripheral vascular disease . Summaries of the literature reviewed are posted at: http://myiiwccselective.blogspot.com.
(Christian Doppler, 1803-1853) itself was the enabler. It allowed multimedia files such as audio and video files to be uploaded along with immediate interactive discussion and feedback. The use of a blog was evaluated amongst the responders and the development of a blog researched as a viable enabler to practice.
The use of a blog as an enabler to practice:
Wikipedia – http://en.wikipdia.org/wiki/Blog defines a blog as (an abridgement of the term web log) a website, usually maintained by an individual, with regular entries of commentary, descriptions of events, or other material such as graphics or video. The ability of readers to leave comments in an interactive format is an important part of many blogs. It was the ability to upload text, audio and video files that was the deciding factor for using a blog as an enabler for this selective. The audio files of arterial and venous sounds, and video files of correct ABI technique were already in existence and it was beyond Understanding obstacles and challenges of the scope of this current work to create new audio and video files; thus it was simply a Implementing ABI in practice settings: matter of using the blog as a means to host these existing files. The site Blogger, owned In order to fully understand current practice and the obstacles and challenges to the by Google, was chosen to host the proposed web log (blog) as this is a very popular site www.blogger.com. Unfortunately, there are implementation of best practice, research was some technical limitations to Blogger as Word, needed amongst healthcare professionals. It Survey Results Actual # Percentage % Excel, PowerPoint or PDF files cannot be was decided that this would be done by survey uploaded directly. These documents can be Total sample of of approximately 160 IIWCC students. This shared through a document hosting site and respondents 160 100% course is run under the auspices of the then a hyperlink placed in the blog entry. Files of University of Toronto and Women’s contacted this nature were placed online through Scribd, College Hospital. Consequently it was agreed Respondents www.pdfcoke.com, described as a big online 35 22% between the author and Faculty that application (by July 25 2008) library where everyone can publish original should be made to the Research Ethics Board content. The Google hosting site was also Surveys fully (REB) at Women’s College for ethics approval of 25 of 35 83% used to directly upload audio files and video files. the survey. The drafted survey was discussed completed with the Faculty and international key opinion Professional role as Enabler feedback: 19 of 35 54% leaders at the World Union of Wound Healing wound care nurses Societies to verify the appropriateness of the Use ABI before Enabler feedback consisted of comments from questions. A clear invitation email was sent to the wound care specialists, IIWCC Faculty and applying 24 of 31 77% respondents to explain the nature of the survey, students and healthcare communications the voluntary nature of completing it and how compression experts. It is a work in progress and the the results would be used. The survey asked Experience of improvement of the blog enabler will be respondents for their professional role, 16 of 35 46% ongoing. Some of the comments have related to conduction ABI country and experience/knowledge in improvements in the appearance, the addition Usage of CAWC/RNAO conducting ABIs. The survey was sent of a biography, a better description below the by email to the current 80 IIWCC Best Practice 30 of 39 77% title in the purpose of the blog. There has been 2007-2008 students and to the 80 Guidelines feedback in respect to any errors on the site or previous IIWCC students from the 2006-2007 Conduct repeat within difficulties with the navigation of links. There have year. The IIWCC group was comprised from a 25 of 35 71% also been comments posted with suggestions to one year mixed professional role, different countries and the content or recommendations for additional No use of enabler 13 of 28 46% levels of skill and experience. links or references. There has been significant Slight benefit or interest in audio and video files being added to Enabler development: significant benefit of the blog. The intention is for the blog to remain online multimedia as an 20 of 26 72% up and running in the long term and that the The blog was initially a mechanism to document content will be updated continuously. enabler to the process of the development of the selective; however, it soon became obvious that the blog knowledge translation
Future development: On reflection and for the future, a Wiki may be more valuable rather than a blog. A blog has some notable limitations. Readers can add comments on a blog but cannot upload information to it. A blog also lists all entries in reverse chronological order. Wikis are often used to create collaborative websites and to power community websites. The collaborative encyclopedia, Wikipedia, is one of the best-known wikis. Transferring the current blog to a wiki would enable others to upload files to the site, thereby making it a more interactive tool for all readers and allow many users to ask and answer questions. The content of the wiki can also be organized as desired and so the most valuable links and resources can be shown first, rather than with a blog where entries are only listed chronologically.
Conclusion: Lower limb ulceration is a significant burden both to the patient and the health care system. Both the RNAO and CAWC best practice guidelines stress the importance of initial thorough patient history and physical examination of the patient. The assessment of Ankle Brachial Pressure Index with the use of a hand-held Doppler is a simple technique that with good training and implementation in clinical practice should be performed routinely as part of any lower limb assessment and should assist in decision making. This selective involved the use of a blog as an enabler to practice. The blog development and survey amongst IIWCC students demonstrated that this new online medium can be a viable means to promote interaction in the knowledge translation. The blog has successfully made audio files of arterial and venous sounds, as well as videos of best practice in conducting ABIs, available to healthcare professionals on the internet. A blog has some limitations and a Wiki may be a more interactive medium. http://myiiwccselective.blogspot.com.
References: 1. Woo K, Lo C, Alavi A, Queen D, Rothman A, Woodbury G, Sibbald M, Noseworthy P, Sibbald RG. An audit of leg and foot ulcer care in an Ontario community care access centre. Wound Care Canada 2007;5(1):S17-S27. 2. Moffat CJ, Franks PJ. Epidemiology and Health Services Research: Implementation of a leg ulcer strategy. B J Derm. 2004;151:857-867. 3. Registered Nurses1 Association of Ontario (RNAO). Nursing Best Practice Guideline: Assessment and Management of Venous leg Ulcers. Toronto: RNAO. 2004. 4. Burrows C, Miller R, Townsend D, Bellefonatine R, MacKean G, Orsted L et al. Best Practice Recommendation for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada. 2006;4(1):45-55 5. Caruana MF, Bradbury AW, Adam DJ. The Validity, Reliability, Reproducibility and Extended Utility of Ankle to Brachial Pressure Index in Current Vascular Surgical Practice. European Journal of Vascular & Endovascular Surgery 2005;29:443-451 Contact: [email protected]
The IIWCC program & poster were supported by an educational grant from ArjoHuntleigh Canada Inc. where John Gregory is Marketing Director.
A Blog as an Enabler for Practice for Lower Limb Assessment Purpose:
D
emystifying Ankle Brachial pressure Index (ABI) assessment through the dissemination of interactive enablers was chosen as a selective for the International Interprofessional Wound Care Course (IIWCC) through the University of Toronto. The need for a simple tool to enable wound care practitioners to confidently conduct ABIs was identified. The aim of the work was to make audio and video resources more widely available to healthcare professionals in one easy to access central location, through a blog as an educational enabler.
The need for vascular assessment: Kevin Woo et al stated in a 2007 audit of leg and foot ulcer care in Ontario that approximately 30% of the clients in both Toronto (29%) and Peel (32.7%) who received community care for ulcerations did so without a diagnosis of the ulcer 1 etiology in their records . Similar percentages were receiving high compression using multi-layer bandaging systems. As well the majority of subjects had not undergone any known special vascular testing (Peel 48.1% and Toronto 58.6%). Christine Moffat & Peter Franks report a high proportion of patients with unspecified ulcer etiology, noting that the level of assessment was poor suggesting that the etiology of ulceration was unproven in most cases2. There are poor implementation protocols despite the availability of best practice guidelines or recommendations developed by the Registered Nurses’ of Ontario (RNAO) and CanadianAssociation of Wound Care (CAWC)3,4. The literature consistently recommends a complete diagnostic assessment for patients with lower extremity ulcers including an Ankle Brachial Pressure Index (ABI) to detect arterial disease. ABI can be relatively inexpensive and easily assessed with a hand-held Doppler. There are a number of simple enablers which help clinical staff cross-reference the ankle and brachial pressures to indicate the pressure index. Whilst the technique is fairly easy and very well documentedin the literature it is not one with which many healthcare professionals are familiar or use regularly. There appears to be a gap in the literature on enablers for conducting ABI examinations. Enablers currently e xist but they are company sponsored and are not cited in the literature. A wider distribution of enablers needs to be made available to assist with the wider implementation of ABI examinations.
Literature review of ABI: Literature searches were conducted through a number of sources. 1) Huntleigh Diagnostics in Cardiff 2) Opinion leaders in the field 3) Best Practice Guidelines/ Recommendations & Consensus Documents 4) Online research 5) WoundPedia Huntleigh Diagnostics were willing to share their library of papers on diagnostic ultrasound relating to ABI,
“The most rewarding research is the one that delights the thinker and at the same time is beneficial to humankind.”
which included original papers, recommended literature and international best practice recommendations. A selection of authors and educators in the field of vascular assessment and leg ulceration were consulted in order to gain further guidance and literature/best practice recommendations. Copies of identified papers/guidelines were obtained and reviewed. Finally, research was conducted through online search engines including MedLine, PubMed, Google Scholar and the Cochrane Database. The literature was not weighted through the AGREE instrument or critically appraised. WoundPedia (www.woundpedia.com) is a wonderful new wound care resource launched at the World Union of Wound Healing Societies 2008. It includes a systematic review by Mario Caruana et al which includes significant information about ABI and its value in 5 evaluating people with venous leg ulcers and asymptomatic peripheral vascular disease . Summaries of the literature reviewed are posted at: http://myiiwccselective.blogspot.com.
(Christian Doppler, 1803-1853) itself was the enabler. It allowed multimedia files such as audio and video files to be uploaded along with immediate interactive discussion and feedback. The use of a blog was evaluated amongst the responders and the development of a blog researched as a viable enabler to practice.
The use of a blog as an enabler to practice:
Wikipedia – http://en.wikipdia.org/wiki/Blog defines a blog as (an abridgement of the term web log) a website, usually maintained by an individual, with regular entries of commentary, descriptions of events, or other material such as graphics or video. The ability of readers to leave comments in an interactive format is an important part of many blogs. It was the ability to upload text, audio and video files that was the deciding factor for using a blog as an enabler for this selective. The audio files of arterial and venous sounds, and video files of correct ABI technique were already in existence and it was beyond Understanding obstacles and challenges of the scope of this current work to create new audio and video files; thus it was simply a Implementing ABI in practice settings: matter of using the blog as a means to host these existing files. The site Blogger, owned In order to fully understand current practice and the obstacles and challenges to the by Google, was chosen to host the proposed web log (blog) as this is a very popular site www.blogger.com. Unfortunately, there are implementation of best practice, research was some technical limitations to Blogger as Word, needed amongst healthcare professionals. It Survey Results Actual # Percentage % Excel, PowerPoint or PDF files cannot be was decided that this would be done by survey uploaded directly. These documents can be Total sample of of approximately 160 IIWCC students. This shared through a document hosting site and respondents 160 100% course is run under the auspices of the then a hyperlink placed in the blog entry. Files of University of Toronto and Women’s contacted this nature were placed online through Scribd, College Hospital. Consequently it was agreed Respondents www.pdfcoke.com, described as a big online 35 22% between the author and Faculty that application (by July 25 2008) library where everyone can publish original should be made to the Research Ethics Board content. The Google hosting site was also Surveys fully (REB) at Women’s College for ethics approval of 25 of 35 83% used to directly upload audio files and video files. the survey. The drafted survey was discussed completed with the Faculty and international key opinion Professional role as Enabler feedback: 19 of 35 54% leaders at the World Union of Wound Healing wound care nurses Societies to verify the appropriateness of the Use ABI before Enabler feedback consisted of comments from questions. A clear invitation email was sent to the wound care specialists, IIWCC Faculty and applying 24 of 31 77% respondents to explain the nature of the survey, students and healthcare communications the voluntary nature of completing it and how compression experts. It is a work in progress and the the results would be used. The survey asked Experience of improvement of the blog enabler will be respondents for their professional role, 16 of 35 46% ongoing. Some of the comments have related to conduction ABI country and experience/knowledge in improvements in the appearance, the addition Usage of CAWC/RNAO conducting ABIs. The survey was sent of a biography, a better description below the by email to the current 80 IIWCC Best Practice 30 of 39 77% title in the purpose of the blog. There has been 2007-2008 students and to the 80 Guidelines feedback in respect to any errors on the site or previous IIWCC students from the 2006-2007 Conduct repeat within difficulties with the navigation of links. There have year. The IIWCC group was comprised from a 25 of 35 71% also been comments posted with suggestions to one year mixed professional role, different countries and the content or recommendations for additional No use of enabler 13 of 28 46% levels of skill and experience. links or references. There has been significant Slight benefit or interest in audio and video files being added to Enabler development: significant benefit of the blog. The intention is for the blog to remain online multimedia as an 20 of 26 72% up and running in the long term and that the The blog was initially a mechanism to document content will be updated continuously. enabler to the process of the development of the selective; however, it soon became obvious that the blog knowledge translation
Future development: On reflection and for the future, a Wiki may be more valuable rather than a blog. A blog has some notable limitations. Readers can add comments on a blog but cannot upload information to it. A blog also lists all entries in reverse chronological order. Wikis are often used to create collaborative websites and to power community websites. The collaborative encyclopedia, Wikipedia, is one of the best-known wikis. Transferring the current blog to a wiki would enable others to upload files to the site, thereby making it a more interactive tool for all readers and allow many users to ask and answer questions. The content of the wiki can also be organized as desired and so the most valuable links and resources can be shown first, rather than with a blog where entries are only listed chronologically.
Conclusion: Lower limb ulceration is a significant burden both to the patient and the health care system. Both the RNAO and CAWC best practice guidelines stress the importance of initial thorough patient history and physical examination of the patient. The assessment of Ankle Brachial Pressure Index with the use of a hand-held Doppler is a simple technique that with good training and implementation in clinical practice should be performed routinely as part of any lower limb assessment and should assist in decision making. This selective involved the use of a blog as an enabler to practice. The blog development and survey amongst IIWCC students demonstrated that this new online medium can be a viable means to promote interaction in the knowledge translation. The blog has successfully made audio files of arterial and venous sounds, as well as videos of best practice in conducting ABIs, available to healthcare professionals on the internet. A blog has some limitations and a Wiki may be a more interactive medium. http://myiiwccselective.blogspot.com.
References: 1. Woo K, Lo C, Alavi A, Queen D, Rothman A, Woodbury G, Sibbald M, Noseworthy P, Sibbald RG. An audit of leg and foot ulcer care in an Ontario community care access centre. Wound Care Canada 2007;5(1):S17-S27. 2. Moffat CJ, Franks PJ. Epidemiology and Health Services Research: Implementation of a leg ulcer strategy. B J Derm. 2004;151:857-867. 3. Registered Nurses1 Association of Ontario (RNAO). Nursing Best Practice Guideline: Assessment and Management of Venous leg Ulcers. Toronto: RNAO. 2004. 4. Burrows C, Miller R, Townsend D, Bellefonatine R, MacKean G, Orsted L et al. Best Practice Recommendation for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada. 2006;4(1):45-55 5. Caruana MF, Bradbury AW, Adam DJ. The Validity, Reliability, Reproducibility and Extended Utility of Ankle to Brachial Pressure Index in Current Vascular Surgical Practice. European Journal of Vascular & Endovascular Surgery 2005;29:443-451 Contact: [email protected]
The IIWCC program & poster were supported by an educational grant from ArjoHuntleigh Canada Inc. where John Gregory is Marketing Director.
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