Evidence-based practice (EBP) is a problem-solving approach to clinical care that incorporates the conscientious use of current best evidence from well-designed studies, a clinician's expertise, and patient values and preferences.1 A primary element of EBP is the personalization of the evidence to accommodate patient circumstances. Failing to utilize evidence in the health care setting is costly and harmful, leading to underuse of effective care and errors in execution.2 The rise in health care costs places an increased impetus on clinical decision-making in examination of the evidence and the costs associated with care. Health care professionals cannot afford to waste time, money, and other resources on ineffective care. Effective clinical outcomes alone are not sufficient. Nurses and other health care professionals must make economically wise decisions, integrating sound clinical outcomes with economics and patients' values and beliefs, to obtain the best possible outcomes.2

Evidence-based practice has had many criticisms. Among them is that it produces cookie-cutter medicine, decreases the context of the clinical practice, de-emphasizes the need for the understanding of pathophysiology, ignores clinical standards such as the physical exam, and relies on statistics to guide medicine.2 Another criticism is the reliance of evidence-based medicine on the randomized controlled trial (RCT) as the "gold standard" for generating evidence. This is particularly troublesome for nursing, as much of nursing work cannot be captured by a RCT.2

The removal of necrotic debris and bacteria from a wound aids in the reduction of inflammation, prevents further infection, and promotes wound healing. Wound debridement is a vital component of the wound bed preparation paradigm.3,4 Different methods of debridement may be used depending on the type of wound; amount of exudate; health care professional knowledge, skill, and judgment; and care setting.4 Debridement methods include surgical debridement, conservative sharp wound debridement (CSWD), enzymatic debridement, autolytic debridement, biological and mechanical debridement. Of note, more than one method may be required at different stages of the wound management process. Debridement of chronic wounds may need to be repeated at regular intervals to remove necrotic tissue and identify viable tissue and dead spaces.4

Choosing a debridement method is a complex decision and depends on various factors that health care professionals must consider, such as the patient's comorbidities, general physical and psychological well-being, pain tolerance, clinician knowledge, skill and judgment, type and severity of the wound, presence of infection, amount of necrosis, size and depth of the wound, vascular sufficiency to the wound bed, patient consent, and environmental setting.4 Health care professionals must assess their level of knowledge, skills, and judgment to determine if they are qualified to perform certain types of debridement safely. In addition, sterile equipment, equipment support, patient positioning, good lighting, and adherence to facility policies and procedures are critical for patient and health care professional safety.4 Wounds should be assessed and categorized as healable, maintenance, or nonhealing based on their potential for healing and the presence of barriers to healing.4 Patients should be assessed for pain and educated and provide consent prior to debridement, and potential barriers to healing should be addressed.4

Given the complexity of the decision-making required to support the action of debridement, health care professionals must be driven by EBP and should rely on best practice guidelines (BPGs), best practice recommendations (BPRs), or consensus statements to guide practice. Best practice guidelines are developed through a rigorous process based on best available evidence related to a given disease, condition, or practice.5 Generally, they are established by a group of subject matter experts, professional associations, or government agencies. The foundation of the guidelines is a systematic review of the available evidence. Best practice guidelines provide a framework for clinical decision-making and are intended to improve patient outcomes by promoting the most effective and appropriate care.5

In comparison, BPRs provide more general principles or recommendations based on expert opinion and experience and scoping reviews of the literature. They provide an overview of actions or strategies that are likely to be effective in achieving specific outcomes or goals and are less prescriptive than BPGs. Best practice recommendations are often developed by professional associations or expert panels and are intended to be flexible, adaptable, and applicable to a wide range of settings.6

Consensus statements, on the other hand, are a representation of expert opinion and reflect content experts' opinions on a given subject.7 Consensus is established using a targeted methodology to identify areas of agreement and disagreement. A consensus document is a formal statement that represents the collective view of a group of experts or stakeholders on a particular topic. In contrast to BPGs and BPRs, which are based primarily on high-level evidence and literature reviews, consensus statements are usually more applicable to situations where evidence is limited or lacking or when cohesion related to a given topic is required.7 Consensus statements are developed through a process of expert consensus building, rather than a formal evidence review, and provide a framework for decision-making and are intended to promote a shared understanding and approach among health care professionals.7

With the goal of developing an adaptable and flexible document that can be used across Canada and over a variety of care settings, the Association of Nurses Specialized in Wound, Ostomy, and Continence Canada (NSWOCC), recently developed Debridement: Canadian Best Practice Recommendations for Nurses (https://www.nswoc.ca/bpr).5 As part of the debridement BPR, a task force completed a scoping review to explore scope of practice, credentials, training, competencies, and regulatory requirements regarding wound debridement for nursing practice in Canada. The scoping review results were synthesized and summarized into 12 BPRs. The statements were reviewed by the task force through a modified Delphi method to achieve consensus. Recommendations that did not meet 70% of agreement were discussed and revised to reach a higher level of consensus. All statements exceeded over 80% agreement. Task force members identified potential peer reviewers who are experts in the wound management field. A total of 38 peer reviewers participated in the peer review process and provided feedback via a secure platform.5

In June 2022, the NSWOCC and the Tissue Viability Society (TVS) reviewed the NSWOCC's Debridement: Canadian BPRs for Nurses. The review determined that there was an opportunity to establish consensus statements related to the Debridement BPR (further information on these consensus statements will be available at nswoc.ca in May 2023). The aim of the consensus document is to support the implementation and utilization of the NSWOCC Debridement BPR into clinical practice on a global level. The consensus statements reflect the NSWOCC Debridement BPR and provide key statements to support the BPR's use in practice. A structured virtual consensus meeting was held on June 10, 2022, and included 7 expert panelists from Canada and the United Kingdom. The panelists convened to discuss and vote on proposed consensus statements related to soft tissue debridement. Panelists represented nurses specialized in wound, ostomy, and continence from Canada and tissue viability nurses and a podiatrist from the United Kingdom. Panelists represented all sectors of the health care system. Panelists' experience in wound care ranged from 5 to 35 years. The meeting was held virtually on the NSWOCC's Zoom platform. The meeting was moderated by a doctoral-prepared NSWOC with experience in facilitation and advanced knowledge of debridement. Fifteen statements related to the knowledge, skill, and judgment; health care professionals' requirements to perform debridement; and further research related to tissue debridement achieved consensus. The panelists engaged in rich discussions, which informed and brought clarity to the consensus statements. After voting was complete, the statements were sent to external reviewers for further consensus.

By using both the NSWOCC's Debridement: Canadian Best Practice Recommendations for Nurses and the consensus statements related to debridement, health care professionals can benefit from the strengths of each type of document. Best practice recommendations have the benefit of a rigorous literature review as its underpinning, while consensus documents provide expert opinions and guidance for real-life practice. Together, the Debridement BPR and the Debridement consensus documents can combine to assist health care professionals in making informed decisions about the best course of action for their patients and improve the quality of care they provide. Additionally, having both types of guidance available can help clinicians stay up to date with the latest advances in wound debridement, which can lead to improved patient outcomes over time.

REFERENCES