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Development of a Decision Support System for Determination of Suitable Dressings for Wounds
DEVELOPMENT OF A DECISION SUPPORT SYSTEM FOR DETERMINATION OF SUITABLE DRESSINGS FOR WOUNDS K. G. Karthick’, M. Miraftab’ and J. Ashton’, ’Institute for Materials Research and Innovation,Universityof Bolton, Deane Road, Bolton BL3 S A B , UK 2BoltonPrimary Care. Trust, Bolton, BL1 IPP,UK
ABSTRACT Given the increasing autonomy of nurses in delivering patient care. and wound care management in particular, they are more than ever engaged indecision making associated with the assessment and treatment of wounds. To select and administer the ‘%ght” dressing from a wide variety of wound dressings available is not an easy task. There are. currently over 650 brands of wound dressings to choose fiom, but it is even more difficult because no one dressing suits all wounds and the choice is dependent on the cause of the wound and will be influenced by the presence of infection, the state of the individual’s health, the nurses prior and existing knowledge of wound care, availability of products and cost. Because of these complexities, nurses are becoming confused regarding wound care practice and research shows that in 85% of cases nurses are using inappropriate dressings and have difficulty in applying their theory and knowledge to their practice. This confusion leads to over consumption o f wound dressings thus increasing the c o d and perhaps more importantly increasing the valuable nursing time required. This web based project aims to optimise the usage of such resources, especially the nursing time available, by reducing the above 85% by developing an evidence based decision support system which would bring together the wound dressing selections made by the nurses from various geographic locations, after being peer reviewed by different tissue viability nurses. It will eventually use an expert system to suggest a choice of wound dressings for a particular wound from the information provided and based on the dressings already selected with the given criteria. It will also provide a comprehensive guideline to wound care and will have an important role as a learning package for student nurses and health workers within wound management. This paper will discuss the methodology used to design such adecision support system. INTRODUCTION Wound management is an ongoing treatment of a wound, by providing appropriate environment for healing, by both direct and indirect methods, together with the prevention of skin breakdown. Proper Management is determined by the wound’s size, depth, severity and location over the care period This management is changing rapidly due to the advancement in technologies which is shedding more light onto the aetiology of the wound and its healing process’. Nurses play a crucial role in the management of wounds They need to have good current knowledge and be more aware of their own wound care practices so as to bring about more effective wound management Nurses are the ones who take care of every single aspect of the patient right from record keeping, prescription handling to basic first aid. They have direct impact on the patients.
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Wound care management is becoming more complex for nurses due to new insights into wound healing and because of the wide variety of w m d dressings that are available Erwin-Toth and Hocevar (1995) stated that there w r e approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favourability and cost (Findlay, 1994). Because of these many different wound care techniques and dressings, nurses are becoming nonplussed regarding wound care practice. Alarmingly, Millers (1994) research showed that in 85% of cases nurses were using inappropriate dressings, and O'Connor found in her studg on wound care that nurses were having difficulty in applying their theory and knowledge to their practice. The results of the study taken by Barlow to find who selects the product used in the management of leg ulcers indicate that 53/57 (93%) district nurses and 33/43 (77%) practice nurses perceive themselves as always or fbquently making the decision. The perception that the majority of GPs never or rarely make this decision was shared by 54 (95Y0) district nurses and 30 (70"h)practice nurses. These results suggest that, for this sam ple, nurses perceive themselves to be the decision-makers on most occasions? Similar study conducted by Boxer and Maynard revealed that registered nurses had significant role in chronic wound management and that their decisions were mostly based on their own experience and that of their colleague$. Another part of this study also suggests that nurses are not using the best available evidence because of inaccessibility of resources and lack of time to search the literature. Nurses also cited difficulty in discriminating between a biased presentation and reliable research. Nurses are basically not accessing the best information that is available to them. They are relying on the nursing colleagues for advice and it also appears that ironically, their colleagues are not accessing the most reliable and conclusive information? In fact nurses in all specialities regularly make clinical decisions on direct patient care, but lack clinical decisions in supervision, management and extended roles! There were also differences in the decisions made between nurses in critical care and other areas of nursing.
RESEARCH AMONGST NURSING STAFF As of 2003, there were 386,359 nurses in the UK. Even 1% representation would mean 3864 nurses and with 301 Primary Care Trusts (PCT) in the United Kingdom (UK) (as of April 2004) we would need at least 13 responses from each PCT. If the sample population was to be reduced to just the tissue viability nurses, nurses from various PCTs from different parts of the country, could be selected with sample of 10 tissue viability nurses from each county. With 39 counties in the UK, this would lead to 390. This would in no way be a representation of the whole nursing population in UK but could still be sufficient representation of the nurses who are active in wound care services. However, the time limit and financial constraints associated to these kinds of activities are not always in favour of such investigation. For this reason convenience sampling was used and carefully designed questionnaires were sent to different PCTs in which at least one of the nurses was known directly or indirectly.
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The prime objectives of the questionnaires were: 0 To identify the factors responsible for selection of wound dressings; 0 To identify the resources that were used to select a wound care product To find out whether they, the wound care nurses, would find it helpful to access the wound care information in a single place; and To find out whether they would be willing to use a computer aided decision making tool even if it might be time consumingto begin with.
Survey results The sample target was set at 100 respondents and a total of 175 questionnaires were sent out by post and few were given out in person. The total number of respondents were only 44. The results were consequently consolidated and analysed using the 44 received responses. No further attempts were made to reach the sample target due to time restrictions. The study showed that 73% (32) of the respondents refer to journals and British National Formulary and 20% (9), some of which (5) included in the above 32, also sought the opinion of their senior members of staff or their colleagues. Only 11% (5) of the respondents used the internet and only two mentioned that they did not use the internet because they did not have access to that resource. The most frequently referred resources were the wound care formulary and the nursing journals. When asked whether they would avoid referring to any of the resources because of the amount of time it consumes, 77% (34 out of 44)gave negative replies. Almost all the respondents except one agreed that they would like to have all the relevant information that helps them in making a choice to be available in a single place. 70% (3 1) of the respondents preferred to have them as a website even though only 11% admitted using the internet. Another 11% (5) apart from the 70% preferred both the website and a CD-ROM while 18% chose just the CD-ROM. The respondents who claimed to have used the internet for research have all preferred to have it as a website and they were either a grade E or grade F nurses. 93% (41) of the respondents expressed interest in using evidence-based decision support system to make a choice, if available. Two respondents said that they would not give it a try. 25 out of the agreed 43 (56%) mentioned that they would use the decision support system regularly and 18 of them said they would even if it was time consuming to being with. The other 44% (18) agreed to use them only when it would be difficult for them to make a decision on the choice of the dressing.
THE NEED FOR A DECISION SUPPORT SYSTEM Shared decision making between doctors and patients is an issue where computer systems may develop an important rule? Cost effective and appropriate care of chronically wounded patients is an outcome that must be attained in the near future as the number of people affected by chronic wounds burgeons in the next 20 years. Algorithms, decision trees, critical pathways, and computer software that include these processes may make this goal possible.
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In wound care alone, there are a number of guidelines in which most of the recommendations are based on very little evidence. This is largely due to the lack of high qualiq randomized controlled trials (Dickson 1996, Renvoize et al, 1997, Haycox et al 1999) . The financial and human cost of pressure ulcers and other wound care conditions is high. Inappropriate wound management can have adverse affects on the healing process and is a waste of precious resources. Thomas and Bale et af have also highlighted variations in the cost of wound management dressings, underlining the importance of appropriatetreatment. The current emphasis on the use of evidence to support clinical interventions has entered a new phase with the establishment of the National Institute for Clinical Excellence (NICE).One of the early issues that are being addressed by NICE is the prevention of pressure sores, which will add considerablytothe body of knowledge about tissue viability. One of the key problems for NICE and other review groups is how best to disseminatetheir findings and recommendations to practitioned. The philosophies behind NICE, Commission for Health Improvement (CHI) and clinical governance are to make real improvements in clinical care - to iron out differences in practice between geographical areas, to implement best practice and eradicate outdated methods, and to make the whole system more accessible and a patient-fiiendly ex rience. Sir Muir Gray’rDirector of Clinical Process, Knowledge Management and Safety at Connecting for Health (CM, formerly the National Programme for Information Technology), has said: “Computerised decision support systems have the potential to support clinicians through the combination of computing technology and upto-date clinical research and information.”
EXPERT SYSTEMS IN MEDICINE Expert systems, as defined by the encyclopaedia, are programmes made up of a set of rules that analyze information (usually supplied by the user of the system) about aspecific class of problems, as well as provide analysis of the problem(s), and, depending upon their design, recommend come of actions in order to implement corrections. In layman’s terms, Expert Systems are computer programmes that are built to perform at a human expert level in a narrow, specialiseddomain. In medical terms, Medical Expert Systems are described as active knowledge systems which use two or more items of patient data to generate casespecific advice (Medical Informatics: Computer Applications in Health Care Shortliffe & Perrault). Although extensive evidence has highlighted the difficultiesencounteredin implementing paper-andpencil practice guidelinesand algorithms, many studies have shown that computerized systems have the potential to overcome these constraints, resultingin improved physician use and patient outcomes’ One such system is the Health Evaluation through Logical Processes W L P ) system, which is the longest running and most successful clinical information system Concepts developed with the HELP system have shown that:
’.
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a) Clinical care can be provided with such a system. b) Computerized decision-support is feasible. c) Computerized decision-support can aid in providing more cost-effective and improved patient care; and d) Clinical user attitudes toward computerized decisionsupport are positive and supportive.'2
Evidence for feasibility of a decision support system Decision Support Systems @SS) are clinical consultation systems that use population statistics and expert knowledge to offer redtime information for clinicians. There have been a number of studies that has proved Clinical Decision Support Systems (CDSS) improve practitioner p e r f o ~ ~ ~ ~ ~ ~ c e ~ ~ . A computerised decision support system, for the management of stroke patients, that incorporated the findings of 960 Markov models examining the decision to prescribe as irin in the secondary prevention of stroke, was developed, and evaluated by Short D et alp4' using 15 GPs from the west Midlands. It was found that the GPs were more certain of their decision making and were more inline with the national guidelines It was suggested that the system made decision making easier, improved feelings of being supported, improved the quality of decision making and increased satisfaction. Tele-health has already been proved as golden opportunity to enhance quality wound care, improve availability, reduce costs, and provide outcomes datak5. A pilot study has proved that there is no difference between the healing times of foot ulcerations that were managed through telemedicine and diabetes foot prognurme groupsk6. Another pilot study which compared telsassessment with live assessment of pressure ulcers in a wound clinic has come out with the result that 89% of the assessor 's have agreed that telsassessment compared well with in-person assessment. This shows the potential accuracy of digital image and photographs in the diagnosis of patient conditions". Many of the previous research work show that guidelines disseminated through traditional educational interventions have minimal impact on physician behaviour. Providing focused training to key people in a practice and supporting subspecialisation through computer decision support may be a more appropriate approach to chronic disease managementin primary can?'. A 2-year project carried out in Canada to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinaryteam." In a randomised controlled trial, Tiemey et al (1993) demonstrated that patients treated by physicians who used a Personal Digital Assistant (PDA) containing decision support, which included costs of specific drugs and diagnostic tests, had less expensive hospital stays. Extrapolation of the cost savings due to reduced costs per admission was in the order of $3 million for the teaching hospital.
Internet as a tool for a decision support system The Internet having evolved as a potentially useful tool for guideline education, dissemination, and implementation because of its open standards and its ability to provide
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concise, relevant clinical information at the location and time of need two clinical DSS's based on national guidelines were developed by Thomas EW et a t o and published on the Internet and both systems improved physician compliance with national guidelines when tested in clinical scenarios. By providing information that is coupled to relevant activity, it is expected that these widely available DSS's will serve as an effective educational tools to positively impact physician behaviod' . Already a web based Critical pathway is being used for radical nephrectomy which has improved health outcomes b reducing the hospital stay and admission charges and by improving the quality of care' Y. The NICE and CM are already undertaking a pilot study to develop and pilot methods for evaluating computerised decision support systems (CDSS). This project is to find whether any existing NICE methodologies such as Technology appraisal progamme could be applied to the evaluation of the CDSS.
DECISION SUPPORT SYSTEM FOR WOUND DRESSING SELECTION Evidence shows that a decision support system has contributed a great deal to the medical field. So an appropriate decision support system is requhd which can collect the data from different trusts. Internet is the commonly available, inexpensive media that is accessible h m any geographic location. So the DSS should be web based. The other advantages of hacng a web based solution are: a) All the information is available fiom a single source. b) All the information can be accessed and updated from any location. c) It can be peer reviewed from any part of the world. In the survey some have stated that they don't have access to the internet in their trusts only to intranet. But current technologies permit the users, through the configuration of a firewall, to access particular sites. The website can also be used as a leaming package where the wound care related materials can be accessed. It can act as a wamd care guideline which concentrates more on the selection process and its description rather than the current research that are being carried out in that particular field. Considering the above, increasing use and availability of internet, a website is being developed which will be carried out in two stages. This paper focuses on the decision support system rather than the learning package. The proposed functional operation and model of the decision support system after its completion is shown inFigures. 1-3.
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Fig 2 Library of possible wounds
LIB I Wound location guide
I
Ixudrlp.
I
a'.
..
'
r.-,m'.,,m.J1I .(w
.a
* Ad *c1
Fig 3 Typical wer interface page
The user identifies the location of the wound on the software system depicting full body figure and is presented with an array of possibilities in terms of wound type, size, depth, age etc. and amount of excaudate excretion, pain leveland so forth. Once the user has entered the requested data, the procedural route follow the decision support system as depicted in Figure 4.
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r I
I I
I I
I I I
I I I
I
I I I
I I
'
:
~
i
Re-fwlualion
Reviewing
Fig 4. Proposed Model ofthe Decision Support System
The users have to login into the system in order to use it. The users are split into 2 user p u p s . The first being the nurses and the second being the peer reviewers who could be experienced specialist nurses or even doctors. The information that is entered by the nurses is stored as Extensible Markup Language (XML) files. XML is a set of rules for defining semantic tags that break a document into parts and identify the different parts of the document. It is a metrtmarkup language that defrnes a syntax in which other domain-specific markup languages can be writtea XML Applications are developed using this XML for a specific domain with its own semantics and v~cabula$~. Some of the well known Applications are Chemical Markup Language (CML) for Chemistry, Gedh4L for Genealogy, Mathematical Markup Language (MathML) for mathematical equations, MusicML for Musical Applications, etc.
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The role of the deciaion support system
The main role of this decision support system is to collect the various characteristics of the wound and the dressing selected for that particular wound. Once a large database starts to build up, subsequent users can enter the characteristicsof the wound andobserve what type of wound dressing were selected for similar wounds. The DSS software will generate the results based on the number of such matched wounds and give a total number of times each type of particular dressing were selected. If a decision is made, then that decision is also added to the database thus updating the DSS accordingly. The role of the reviewer
For each entry that is being made into the system. A reviewer has to aprove that the information provided is true. A reference to the evidence used may be attached so that it helps the reviewer to approve quickly. If the reviewer thinks that the choice made is inappropriate, helshe may reject it from being entered into the llain database server and can state a reason as to why it was rejected and send it back which can then be viewed by just that particular nurse. Provision can be provided where the nurse can attach more evidence and send it for reconsideration. Advantages of the DSS
The main advantage of this system is the integration I accumulation of the nationwide wound care information in a single location. Such information helps in making a decision for selection of appropriate wound dressings It acts as a comprehensive database for wound care research. Since the decision support system is integrated with a learning package which is more of a wound care guideline than a latest news provider,it can be used to train staff as well as assist them with their professionaljdgement. CONCLUSION
In this research, the issues concerning the management of wounds by the nurses were reviewed and possible solution to the selection of appropriate wound dressings for given wound type was identified. The solution being a web based decision support system that helps to identi@ the appropriate wound dressing for a given wound. A nationwide survey was conducted to find out the feasibility of such a system and 96% (43) of the respondents showed interest in such a system. The paper also discussed the need for Decision Support System and the methodology and technology with which such a web based decision support system is being developed. This DSS, once fully developed, aims to reduce the confusion among the nurses in selecting appropriate wound dressings and also serve as a comprehensive guideline to wound care management.
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REFERENCES 1 C Dowsett, ‘Developing wound management guidelines for community nurses’, British Journal of Community Nursing, 2002 7(2) 62-68.
2 B M King, ‘UK Wound management; Nurses’ knowledge; Research studies’, Journal of Wound Care, July 2000 9 0 343-346. 3 I Barlow, ‘Prescribing for leg ulcers in general practice, Part 2, Journal of Wound Care, Sep 1999 8(8) 390 - 393. 4 E Boxer and C Maynard, ‘The management of chronic wounds: factors that affect nurses’ decision-making’, Journal of Wound Care, Sep 1999 8(8) 409 - 412.
5 I Barlow, ‘Prescniing for leg ulcers in general practice, Part P, Journal of Wound Care, Aug 1999 S(7) 369-371. 6 N A Bakalis and R Watson, ‘Nurses’ decision making in clinical practice’, Nursing Standard, Feb 16 2005 19(23) 33-39.
7 BC Delany, DA Fitzmauricc, A Riaz and R Hobbs, ‘Can computerised decision support systems deliver improved quality in primary care?’, BUI, Nov 13 1999 No 3 19,1281. 8 A Tong, ‘Clinical Guidelines: Can they be effective? Amanda Tong questions, NT Plus, Mar 200 1 97(9) Pg III - IV. 9 J Unsworth and H Boon, ’Developing Internet based wound care information’, British Journal of CommunityNursing, 1999 4(9) 426-435. 10 The New NHS: Modem, dependable, Department of Health, The Stationery Office, London, 1997. 1 1 R B Elson and D P Connelly, ‘Computerized patient records in primary care: Their role in mediating guideline-driven physician behaviour change’, Archives of Family Medicine, 1995,4,698-705.
12 P J Haug, B H Rocha and R S Evans, ‘Decision support in medicine: Lessons fiom the HELP system’, Int JMed Inj Mar 2003 69(Iss 2-3) 273-284. 13 A X Garg, N K Adhikari, H McDonald and M P RosasArellano, ‘Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review‘, The Journal Of The American Medical Association, Mar 9,2005 2 9 3 ( I ~10) ~ 1223-1238.
14 D Short, M Frischer andJ Bashford, ‘The development and evaluation of a computerised decision support system for primary care based upon ‘patient profile decision analysis’, Informatics in Primary Care, December 1,2003 11(4) 195-202.
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15 V J Ablaza and J Fisher, ‘Wound care via Telemedicine: The wave of the fitme’, Home Healthcare Consultunt, 1998 5(8) 12- 16. 16 W A Wilbright, J A Birke et al, ‘The use of Telemedicine in the management of diabetes-related foot ulceration: A Pilot study’, Advances in Skin and Wound Care, 2004 ISS 17,232-278.
17 P E Houghton, C B Kincaid, K E Campbell, M G Woodbury and D H Keast, ‘Photographic assessment of the appearance of chronic pressure and leg ulcerd, Ostomy Wound Management, 2000 46(Iss 4) 28-30. 18 Eccles et al’s Editorial Letter, B W , Feb 2003, No 326,394. 19 H F Clarke, C Bradley, S Whytock, S Handfield, C Van Der Wal and S Gundry, ‘Pressure ulcers: Implementation of evidencebased nursing practice’, Journal of Advanced Nursing, 2005 49(Iss 6 ) 578-590. 20 K W Thomas, C S Dayton and M W Peterson, ‘Evaluation of internet-based clinical decision support systems’, Journal of Medical Internet Research Oct - Dec 1999 l(Iss 2) E6. 21 J H Wandersee, ‘Concept mapping and the cartography of cognition’; Journal of Research in Science Teaching, I990 27( 10) 923-936.
22 P L Chang, Y C Li and S H Lee, ‘The differences in health outcomes between web based and paper-based implementation of a clinical pathway for radical nephrectomy’, BJU International, 2002 90 522-528. 23 M Leventhal, D Lewis and M Fuchs, Designing XU5 Internet Applications, New Jersey, Prentice Hall PTR, 1998.
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ABSTRACT Given the increasing autonomy of nurses in delivering patient care. and wound care management in particular, they are more than ever engaged indecision making associated with the assessment and treatment of wounds. To select and administer the ‘%ght” dressing from a wide variety of wound dressings available is not an easy task. There are. currently over 650 brands of wound dressings to choose fiom, but it is even more difficult because no one dressing suits all wounds and the choice is dependent on the cause of the wound and will be influenced by the presence of infection, the state of the individual’s health, the nurses prior and existing knowledge of wound care, availability of products and cost. Because of these complexities, nurses are becoming confused regarding wound care practice and research shows that in 85% of cases nurses are using inappropriate dressings and have difficulty in applying their theory and knowledge to their practice. This confusion leads to over consumption o f wound dressings thus increasing the c o d and perhaps more importantly increasing the valuable nursing time required. This web based project aims to optimise the usage of such resources, especially the nursing time available, by reducing the above 85% by developing an evidence based decision support system which would bring together the wound dressing selections made by the nurses from various geographic locations, after being peer reviewed by different tissue viability nurses. It will eventually use an expert system to suggest a choice of wound dressings for a particular wound from the information provided and based on the dressings already selected with the given criteria. It will also provide a comprehensive guideline to wound care and will have an important role as a learning package for student nurses and health workers within wound management. This paper will discuss the methodology used to design such adecision support system. INTRODUCTION Wound management is an ongoing treatment of a wound, by providing appropriate environment for healing, by both direct and indirect methods, together with the prevention of skin breakdown. Proper Management is determined by the wound’s size, depth, severity and location over the care period This management is changing rapidly due to the advancement in technologies which is shedding more light onto the aetiology of the wound and its healing process’. Nurses play a crucial role in the management of wounds They need to have good current knowledge and be more aware of their own wound care practices so as to bring about more effective wound management Nurses are the ones who take care of every single aspect of the patient right from record keeping, prescription handling to basic first aid. They have direct impact on the patients.
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Wound care management is becoming more complex for nurses due to new insights into wound healing and because of the wide variety of w m d dressings that are available Erwin-Toth and Hocevar (1995) stated that there w r e approximately 400 brands of wound care dressings on the market to choose from and that wound care is made even more difficult because no one dressing method suits all wounds and the choice is dependent on the cause of the wound, infection, favourability and cost (Findlay, 1994). Because of these many different wound care techniques and dressings, nurses are becoming nonplussed regarding wound care practice. Alarmingly, Millers (1994) research showed that in 85% of cases nurses were using inappropriate dressings, and O'Connor found in her studg on wound care that nurses were having difficulty in applying their theory and knowledge to their practice. The results of the study taken by Barlow to find who selects the product used in the management of leg ulcers indicate that 53/57 (93%) district nurses and 33/43 (77%) practice nurses perceive themselves as always or fbquently making the decision. The perception that the majority of GPs never or rarely make this decision was shared by 54 (95Y0) district nurses and 30 (70"h)practice nurses. These results suggest that, for this sam ple, nurses perceive themselves to be the decision-makers on most occasions? Similar study conducted by Boxer and Maynard revealed that registered nurses had significant role in chronic wound management and that their decisions were mostly based on their own experience and that of their colleague$. Another part of this study also suggests that nurses are not using the best available evidence because of inaccessibility of resources and lack of time to search the literature. Nurses also cited difficulty in discriminating between a biased presentation and reliable research. Nurses are basically not accessing the best information that is available to them. They are relying on the nursing colleagues for advice and it also appears that ironically, their colleagues are not accessing the most reliable and conclusive information? In fact nurses in all specialities regularly make clinical decisions on direct patient care, but lack clinical decisions in supervision, management and extended roles! There were also differences in the decisions made between nurses in critical care and other areas of nursing.
RESEARCH AMONGST NURSING STAFF As of 2003, there were 386,359 nurses in the UK. Even 1% representation would mean 3864 nurses and with 301 Primary Care Trusts (PCT) in the United Kingdom (UK) (as of April 2004) we would need at least 13 responses from each PCT. If the sample population was to be reduced to just the tissue viability nurses, nurses from various PCTs from different parts of the country, could be selected with sample of 10 tissue viability nurses from each county. With 39 counties in the UK, this would lead to 390. This would in no way be a representation of the whole nursing population in UK but could still be sufficient representation of the nurses who are active in wound care services. However, the time limit and financial constraints associated to these kinds of activities are not always in favour of such investigation. For this reason convenience sampling was used and carefully designed questionnaires were sent to different PCTs in which at least one of the nurses was known directly or indirectly.
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The prime objectives of the questionnaires were: 0 To identify the factors responsible for selection of wound dressings; 0 To identify the resources that were used to select a wound care product To find out whether they, the wound care nurses, would find it helpful to access the wound care information in a single place; and To find out whether they would be willing to use a computer aided decision making tool even if it might be time consumingto begin with.
Survey results The sample target was set at 100 respondents and a total of 175 questionnaires were sent out by post and few were given out in person. The total number of respondents were only 44. The results were consequently consolidated and analysed using the 44 received responses. No further attempts were made to reach the sample target due to time restrictions. The study showed that 73% (32) of the respondents refer to journals and British National Formulary and 20% (9), some of which (5) included in the above 32, also sought the opinion of their senior members of staff or their colleagues. Only 11% (5) of the respondents used the internet and only two mentioned that they did not use the internet because they did not have access to that resource. The most frequently referred resources were the wound care formulary and the nursing journals. When asked whether they would avoid referring to any of the resources because of the amount of time it consumes, 77% (34 out of 44)gave negative replies. Almost all the respondents except one agreed that they would like to have all the relevant information that helps them in making a choice to be available in a single place. 70% (3 1) of the respondents preferred to have them as a website even though only 11% admitted using the internet. Another 11% (5) apart from the 70% preferred both the website and a CD-ROM while 18% chose just the CD-ROM. The respondents who claimed to have used the internet for research have all preferred to have it as a website and they were either a grade E or grade F nurses. 93% (41) of the respondents expressed interest in using evidence-based decision support system to make a choice, if available. Two respondents said that they would not give it a try. 25 out of the agreed 43 (56%) mentioned that they would use the decision support system regularly and 18 of them said they would even if it was time consuming to being with. The other 44% (18) agreed to use them only when it would be difficult for them to make a decision on the choice of the dressing.
THE NEED FOR A DECISION SUPPORT SYSTEM Shared decision making between doctors and patients is an issue where computer systems may develop an important rule? Cost effective and appropriate care of chronically wounded patients is an outcome that must be attained in the near future as the number of people affected by chronic wounds burgeons in the next 20 years. Algorithms, decision trees, critical pathways, and computer software that include these processes may make this goal possible.
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In wound care alone, there are a number of guidelines in which most of the recommendations are based on very little evidence. This is largely due to the lack of high qualiq randomized controlled trials (Dickson 1996, Renvoize et al, 1997, Haycox et al 1999) . The financial and human cost of pressure ulcers and other wound care conditions is high. Inappropriate wound management can have adverse affects on the healing process and is a waste of precious resources. Thomas and Bale et af have also highlighted variations in the cost of wound management dressings, underlining the importance of appropriatetreatment. The current emphasis on the use of evidence to support clinical interventions has entered a new phase with the establishment of the National Institute for Clinical Excellence (NICE).One of the early issues that are being addressed by NICE is the prevention of pressure sores, which will add considerablytothe body of knowledge about tissue viability. One of the key problems for NICE and other review groups is how best to disseminatetheir findings and recommendations to practitioned. The philosophies behind NICE, Commission for Health Improvement (CHI) and clinical governance are to make real improvements in clinical care - to iron out differences in practice between geographical areas, to implement best practice and eradicate outdated methods, and to make the whole system more accessible and a patient-fiiendly ex rience. Sir Muir Gray’rDirector of Clinical Process, Knowledge Management and Safety at Connecting for Health (CM, formerly the National Programme for Information Technology), has said: “Computerised decision support systems have the potential to support clinicians through the combination of computing technology and upto-date clinical research and information.”
EXPERT SYSTEMS IN MEDICINE Expert systems, as defined by the encyclopaedia, are programmes made up of a set of rules that analyze information (usually supplied by the user of the system) about aspecific class of problems, as well as provide analysis of the problem(s), and, depending upon their design, recommend come of actions in order to implement corrections. In layman’s terms, Expert Systems are computer programmes that are built to perform at a human expert level in a narrow, specialiseddomain. In medical terms, Medical Expert Systems are described as active knowledge systems which use two or more items of patient data to generate casespecific advice (Medical Informatics: Computer Applications in Health Care Shortliffe & Perrault). Although extensive evidence has highlighted the difficultiesencounteredin implementing paper-andpencil practice guidelinesand algorithms, many studies have shown that computerized systems have the potential to overcome these constraints, resultingin improved physician use and patient outcomes’ One such system is the Health Evaluation through Logical Processes W L P ) system, which is the longest running and most successful clinical information system Concepts developed with the HELP system have shown that:
’.
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a) Clinical care can be provided with such a system. b) Computerized decision-support is feasible. c) Computerized decision-support can aid in providing more cost-effective and improved patient care; and d) Clinical user attitudes toward computerized decisionsupport are positive and supportive.'2
Evidence for feasibility of a decision support system Decision Support Systems @SS) are clinical consultation systems that use population statistics and expert knowledge to offer redtime information for clinicians. There have been a number of studies that has proved Clinical Decision Support Systems (CDSS) improve practitioner p e r f o ~ ~ ~ ~ ~ ~ c e ~ ~ . A computerised decision support system, for the management of stroke patients, that incorporated the findings of 960 Markov models examining the decision to prescribe as irin in the secondary prevention of stroke, was developed, and evaluated by Short D et alp4' using 15 GPs from the west Midlands. It was found that the GPs were more certain of their decision making and were more inline with the national guidelines It was suggested that the system made decision making easier, improved feelings of being supported, improved the quality of decision making and increased satisfaction. Tele-health has already been proved as golden opportunity to enhance quality wound care, improve availability, reduce costs, and provide outcomes datak5. A pilot study has proved that there is no difference between the healing times of foot ulcerations that were managed through telemedicine and diabetes foot prognurme groupsk6. Another pilot study which compared telsassessment with live assessment of pressure ulcers in a wound clinic has come out with the result that 89% of the assessor 's have agreed that telsassessment compared well with in-person assessment. This shows the potential accuracy of digital image and photographs in the diagnosis of patient conditions". Many of the previous research work show that guidelines disseminated through traditional educational interventions have minimal impact on physician behaviour. Providing focused training to key people in a practice and supporting subspecialisation through computer decision support may be a more appropriate approach to chronic disease managementin primary can?'. A 2-year project carried out in Canada to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinaryteam." In a randomised controlled trial, Tiemey et al (1993) demonstrated that patients treated by physicians who used a Personal Digital Assistant (PDA) containing decision support, which included costs of specific drugs and diagnostic tests, had less expensive hospital stays. Extrapolation of the cost savings due to reduced costs per admission was in the order of $3 million for the teaching hospital.
Internet as a tool for a decision support system The Internet having evolved as a potentially useful tool for guideline education, dissemination, and implementation because of its open standards and its ability to provide
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concise, relevant clinical information at the location and time of need two clinical DSS's based on national guidelines were developed by Thomas EW et a t o and published on the Internet and both systems improved physician compliance with national guidelines when tested in clinical scenarios. By providing information that is coupled to relevant activity, it is expected that these widely available DSS's will serve as an effective educational tools to positively impact physician behaviod' . Already a web based Critical pathway is being used for radical nephrectomy which has improved health outcomes b reducing the hospital stay and admission charges and by improving the quality of care' Y. The NICE and CM are already undertaking a pilot study to develop and pilot methods for evaluating computerised decision support systems (CDSS). This project is to find whether any existing NICE methodologies such as Technology appraisal progamme could be applied to the evaluation of the CDSS.
DECISION SUPPORT SYSTEM FOR WOUND DRESSING SELECTION Evidence shows that a decision support system has contributed a great deal to the medical field. So an appropriate decision support system is requhd which can collect the data from different trusts. Internet is the commonly available, inexpensive media that is accessible h m any geographic location. So the DSS should be web based. The other advantages of hacng a web based solution are: a) All the information is available fiom a single source. b) All the information can be accessed and updated from any location. c) It can be peer reviewed from any part of the world. In the survey some have stated that they don't have access to the internet in their trusts only to intranet. But current technologies permit the users, through the configuration of a firewall, to access particular sites. The website can also be used as a leaming package where the wound care related materials can be accessed. It can act as a wamd care guideline which concentrates more on the selection process and its description rather than the current research that are being carried out in that particular field. Considering the above, increasing use and availability of internet, a website is being developed which will be carried out in two stages. This paper focuses on the decision support system rather than the learning package. The proposed functional operation and model of the decision support system after its completion is shown inFigures. 1-3.
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Fig 2 Library of possible wounds
LIB I Wound location guide
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Fig 3 Typical wer interface page
The user identifies the location of the wound on the software system depicting full body figure and is presented with an array of possibilities in terms of wound type, size, depth, age etc. and amount of excaudate excretion, pain leveland so forth. Once the user has entered the requested data, the procedural route follow the decision support system as depicted in Figure 4.
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Fig 4. Proposed Model ofthe Decision Support System
The users have to login into the system in order to use it. The users are split into 2 user p u p s . The first being the nurses and the second being the peer reviewers who could be experienced specialist nurses or even doctors. The information that is entered by the nurses is stored as Extensible Markup Language (XML) files. XML is a set of rules for defining semantic tags that break a document into parts and identify the different parts of the document. It is a metrtmarkup language that defrnes a syntax in which other domain-specific markup languages can be writtea XML Applications are developed using this XML for a specific domain with its own semantics and v~cabula$~. Some of the well known Applications are Chemical Markup Language (CML) for Chemistry, Gedh4L for Genealogy, Mathematical Markup Language (MathML) for mathematical equations, MusicML for Musical Applications, etc.
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The role of the deciaion support system
The main role of this decision support system is to collect the various characteristics of the wound and the dressing selected for that particular wound. Once a large database starts to build up, subsequent users can enter the characteristicsof the wound andobserve what type of wound dressing were selected for similar wounds. The DSS software will generate the results based on the number of such matched wounds and give a total number of times each type of particular dressing were selected. If a decision is made, then that decision is also added to the database thus updating the DSS accordingly. The role of the reviewer
For each entry that is being made into the system. A reviewer has to aprove that the information provided is true. A reference to the evidence used may be attached so that it helps the reviewer to approve quickly. If the reviewer thinks that the choice made is inappropriate, helshe may reject it from being entered into the llain database server and can state a reason as to why it was rejected and send it back which can then be viewed by just that particular nurse. Provision can be provided where the nurse can attach more evidence and send it for reconsideration. Advantages of the DSS
The main advantage of this system is the integration I accumulation of the nationwide wound care information in a single location. Such information helps in making a decision for selection of appropriate wound dressings It acts as a comprehensive database for wound care research. Since the decision support system is integrated with a learning package which is more of a wound care guideline than a latest news provider,it can be used to train staff as well as assist them with their professionaljdgement. CONCLUSION
In this research, the issues concerning the management of wounds by the nurses were reviewed and possible solution to the selection of appropriate wound dressings for given wound type was identified. The solution being a web based decision support system that helps to identi@ the appropriate wound dressing for a given wound. A nationwide survey was conducted to find out the feasibility of such a system and 96% (43) of the respondents showed interest in such a system. The paper also discussed the need for Decision Support System and the methodology and technology with which such a web based decision support system is being developed. This DSS, once fully developed, aims to reduce the confusion among the nurses in selecting appropriate wound dressings and also serve as a comprehensive guideline to wound care management.
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15 V J Ablaza and J Fisher, ‘Wound care via Telemedicine: The wave of the fitme’, Home Healthcare Consultunt, 1998 5(8) 12- 16. 16 W A Wilbright, J A Birke et al, ‘The use of Telemedicine in the management of diabetes-related foot ulceration: A Pilot study’, Advances in Skin and Wound Care, 2004 ISS 17,232-278.
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