Clare is a clinical academic at Leeds Teaching Hospitals, and working as a Senior Clinical Nurse Specialist in Tissue Viability for the last 13 years.

 Prior to that she worked as a Nurse Specialist in negative pressure wound therapy and as a staff nurse in colorectal surgery at LTHT.

Clare completed her doctorate in 2020, and also has an MSc in Nursing and a PGCert in Tissue Viability. Her PhD research focused on the use devices for the prevention of heel pressure ulcers, which she has presented at national and international conferences, and has informed a successful NIHR HTA Grant “WHiTE-PRESSURE 3”. This is a multi-centred three arm RCT comparing offloading devices, heel cushioning pads and standard care for the prevention of heel pressure ulcers in hip fracture patients. Clare has also received funding from NW R&D as part of the post-doctorate bridging scheme to support the development of her application for an NIHR ACAF. She is currently building a nurse led research delivery service in Tissue Viability.

Clare is a trustee for the Society of Tissue Viability, working on national education projects, organisation of their annual conference, collaborating with the Wounds Research Network (WReN) and is associate editor for the society’s journal “The Journal of Tissue Viability”.

Presentation at The SoTV/EWMA 2024 Conference, London

PRESSURE 3: Building the links between evidence, perceptions and the reality of clinical practice in heel pressure ulcer prevention: The pathway to a successful investigation of effectiveness

Learning objectives

After attending this session, persons will be able to:

• Understand the processes and exploratory work required to develop a successful clinical trial
• Understand how platform trials can improve trial recruitment

Abstract

Numerous devices exist for the prevention of heel pressure ulcers(PU). Evidence on relative effectiveness and clinical utility of each device is minimal.

Aims and method: To plan an RCT to inform the evidence base, we needed to:

• Establish the evidence base with systematic review(1)
• Understand current practice(2)
• Identify what informs stakeholder decision making and existence of clinical equipoise(2)
• Identify high risk populations
• Identify an efficient process to deliver a trial with low incidence rates

Results: No evidence for Constant Low Pressure(CLP) devices, poor quality evidence for off-loading devices (15 RCTs identified. 2 trials (n= 422), outcome of Cat 2 PU medium quality RR 0.08 95% CI 0.01-0.67).

Current practice was variable and informed by stakeholder and peer preference, which also influences clinical equipoise.

Differences were observed in what stakeholders believed was happening in clinical practice, and what actually happens.

Fractured neck of femur patients were identified as high risk group with variable practices. An established research platform (WHiTE) was used to optimise recruitment to a 3-arm RCT of heel PU prevention devices.

Conclusions: Establishing evidence and current practice and working with an established research platform successful trial funding was achieved for a 3-arm RCT. Recruitment is underway.

References:

1. Greenwood, C. et al. (2022)https://doi.org/10.1016/j.jtv.2022.09.009
2. Greenwood, C. et al. (2023)https://doi.org/10.1016/j.ijnurstu.2023.104479

Presentation at The Society of Tissue Viability 2023 Conference

Interviews with Tissue Viability Nurses about their perceptions of how we use devices for the prevention of heel pressure ulcers in acute care

Objectives

After attending this session, persons will be able to:

• Explore how and why offloading devices are used in clinical practice in the absence of a robust evidence base to guide their use
• Understand how interviews with Tissue Viability Nurse Specialists provide a real world picture of current practices

Abstract

Background – Heel pressure ulcers can cause pain, reduce mobility, lead to longer hospital stays and in severe cases can lead to sepsis, amputation, and death. Offloading boots are marketed as heel pressure ulcer prevention devices, working by removing pressure to the heel, yet there is little good quality evidence about their clinical effectiveness. Given that evidence is not guiding use of these devices, this study aims to explore, how, when, and why these devices are used in hospital settings.

Methods – Eight Tissue Viability Nurse Specialists from across the UK (England, Wales, and Northern Ireland) were interviewed to explore how, when, and why offloading devices are implemented and used in clinical practice for the prevention of heel pressure ulcers.

Results – These interviews developed three overarching theories into how these devices are used in acute care:

1. “Proactively” for the prevention of heel pressure ulcers
2. “Reactively” to treat heel pressure ulcers and mimimise deterioration of early stage pressure ulcers
3. Patient factors that influence device use

Conclusions – Offloading devices were used in clinical practice by all of the interviewees, but they were viewed as not being suitable to be used by every patient, at every point in their inpatient journey, nor was it financially viable. However, through identifying “at risk” patient groups that can maintain use of the devices could lead to a more pro-active and cost effective use of the devices.

Presentation at The Society of Tissue Viability 2022 Conference

Making sense of the evidence

Objectives

After attending this session, persons will be able to:

• Have a better understanding of evidence-based practice, and the hierarchy of evidence
• Have a better understanding on how to appraise the available evidence
• Be able to understand how evidence should be used to inform guidelines and best practice statements, and how these should guide clinical practice

Abstract

The evidence on which we base practice can come from a range of sources including research findings, basic science, clinical knowledge, and expert opinion. Being able to appraise evidence from such a wide range of sources can be difficult, and although Randomised Controlled Trials and Meta-analysis are seen as the ‘gold standard’ for evidence-based practice, other sources of evidence can be just as important.

This interactive session will give an overview of the different sources of evidence and how they can be used to inform practice and guidelines, as well as future research proposals.

Presentation at the WReN Scientific Meeting, Glasgow, May 2022

WHITE/PRESSURE3: World Hip Trauma Evaluation – Pressure ulcer prevention 3; A randomised clinical trial assessing early use of heel specific adjunct devices for heel pressure ulcer prevention in people with a fractured hip

Objectives

After attending this session, persons will be able to:

• Understand the current evidence base with regards to the use of devices for the prevention of heel pressure ulcers
• An introduction to a newly HTA funded RCT, and the importance of this research

Abstract 

Patients admitted with a fractured hip are at risk of heel pressure ulcers (HPU) which impact upon rehabilitation, recovery, and independence. Whilst available in the NHS, the use of heel specific adjunct devices for HPU prevention is not common even in high-risk patient populations.

AIM: to evaluate the clinical and cost-effectiveness of the use of early initiation of heel off-loading devices and constant low-pressure devices for the prevention of Category≥ 2 HPUs in hip fractures patients over the age of 60, recruited within 48 hours of admission.

DESIGN: pragmatic, multi-centre, randomised, 3 arm parallel group trial with economic evaluation.

SETTING: the trial will be embedded within the World Hip Trauma Evaluation (WHiTE) Platform trials framework in 30 pre-established hip fracture centres.

HEALTH TECHNOLOGIES: 3102 patients (1034 per group) will be randomised to:

1. a) Standard care plus adjunct heel off-loading devices which eliminate heel pressure including heel lift/suspension boots and off-loading wedges
2. b) Standard care plus adjunct constant low-pressure device (CLP) which distribute pressure over a larger surface area, reducing the magnitude of the applied pressure, including foam and gel pads and boots
3. c) Standard care alone which typically includes the provision of high specification foam or specialised air mattress; an electric profiling bed and repositioning more frequently than 3-hourly.

ANALYSES: On an intention to treat basis, proportions of new Category ≥2 HPUs reported for each group and for the two comparisons: heel offloading versus standard care and CLP versus standard care. Economic assessment methods will align with NICE Reference Case