1. Ayello, Elizabeth A. PhD, RN, APRN,BC, CWOCN, FAPWCA, FAAN
  2. Sibbald, R. Gary BSc, MD, FRCPC (Med) (Derm), FAPWCA, MEd

Article Content

At the Third Congress of the World Union of Wound Healing Societies (WUWHS), to be held June 4 to 6, 2008, in Toronto, Ontario, Canada, wound care evidence from around the world will be critiqued and summarized, as discussed in the Guest Editorial in the September issue of Advances in Skin & Wound Care. The theme of the Congress is the clinical translation of wound care knowledge to benefit patients with chronic wounds worldwide. This process involves the inclusion of evidence from 3 different perspectives:


* efficacy-it works in idealized patients


* efficiency-it works in usual patients


* effectiveness-it has benefits and reasonable costs.



The current organization of the evidence base for wound care may not encompass all 3 perspectives. For the WUWHS Congress, however, we propose adopting a modification in line with this sentiment from Sackett et al:1 "Good doctors [and other health care professionals] use both individual clinical expertise and the best available external evidence and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients." This combination of the scientific evidence base and expert opinion contextualized to local practice is referred to as evidence-informed medicine.


The original work of Sackett et al1,2 embraces the judicious use of expert opinion within evidence-based medicine. This can include the patient's preferences and his or her family's experiences with illness-often forgotten in the rush for evidence from randomized controlled trials (RCTs). One of the pitfalls of RCTs in wound research, in fact, is the strict subject selection, which typically eliminates most "usual" patients and leaves clinicians at a disadvantage when attempting to translate RCT results to the real world of clinical practice.


Eye on Tradition

In preparation for the Third Congress of the WUWHS, we began thinking about easy-to-use aids to navigate through our expanded definition of the wound care evidence base. We can draw on a Canadian tradition: the Inukshuk carved by the native Northern Canadian Inuit people (Figure 1). Using a keen sense of observation that combines perception and skill, the artist examines the piece from every angle and then cuts it to bring out all that is hidden inside. Today, Inukshuks are used as trail markers by the Canadian Inuit people, and this has become a national symbol often seen at airport and other public sites in Canada.

Figure 1 - Click to enlarge in new windowFigure 1. INUKSHUK

To reinterpret the evidence-based paradigm, we will combine the evidence base with expert opinion-both professional and patient-based from experience-through use of the Appraisal of Guidelines Research & Evaluation (AGREE) Instrument3 to benchmark the quality of the guidelines we examine. This tool will help us identify high-quality guidelines from a methodological and clinical perspective. The guideline then becomes an important proposed category, combining scientific evidence, expert opinion, and patient preference through an idealized process of integrating these 3 domains.


Evidence Groups

The categories of evidence that are nonhierarchical or nonlinear for a data summary include the following:


Category: Guidelines-AGREE tool scoring


* Excellent: 4****


* Good: 3***


* Fair: 2**



Category: Systematic reviews and random controlled trial


* Meta-analysis


* RCTs: More than 1


* RCTs: Single study



Category: Clinical studies


* Double-blind comparative


* Case series


* Case report



Category: Expert opinion


* Formal developed consensus (Delphi)


* National/international consensus


* Single constituency: opinions



Category: Animal studies


* Basic science


* Models of wound healing process


* Product evaluation



Category: In vitro and ex vivo studies


* Engineering, constructs


* Biology, mode of action


* Toxicity and safety



All 6 of these categories provide different aspects of the evidence to complete the holistic data summary for optimal patient care (Figure 2).

Figure 2 - Click to enlarge in new windowFigure 2. WUWHS CATEGORIES OF EVIDENCE

Opinions, Please

We would like to know what you think of this method of collecting key information as a basis for the evidence base summaries. Visit the Web site, to offer feedback.


We are also looking for volunteers to rate guidelines within various categories using the AGREE instrument scoring system. The tutorial is about 2 hours long; it takes about 1 hour to complete a rating scale for each guideline. We would ask each rater to complete 3 or more guidelines. Participants may also select a chat group in the evidence base summary to help facilitate the collection and synthesis of the most relevant information for everyday practice. See the WUWHS Web site for more information.


The 2008 WUWHS meeting will allow attendees to survey their knowledge through the evidence base summary, then select sessions for their personal knowledge gaps. The closing plenary session will summarize the key new information from each of the streams found on the WUWHS Web site, and participants will receive a CD-ROM or downloadable version of the information for future reference. All attendees will leave with a toolkit for optimizing the treatment of patients and improving outcomes.


The world is coming to Toronto. We hope that you will be there, too.




1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-2. [Context Link]


2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes, RB. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh, Scotland: Churchill Livingston; 2000. [Context Link]


3. Appraisal of Guidelines Research & Evaluation (AGREE) Instrument. Available at: Accessed August 22, 2006. [Context Link]