To identify evidence-based wound infection management recommendations from structured systematic literature searches, 19 multidisciplinary wound care professional members of the Association for the Advancement of Wound Care (AAWC, the host society), the Wound Healing Society, the Canadian Association for Enterostomal Therapy, and the Mexican Wound Healing Society (AMCICHAC) collaborating as part of the International Consolidated Wound Infection Guideline Task Force (ICWIG TF) explored barriers to evidence-based wound infection practice; conducted structured literature searches to identify evidence supporting recommendations for wound infection diagnosis, prevention, and treatment; evaluated each recommendation’s multidisciplinary construct validity; and content-validated clinical relevance and strength of recommendation (SOR), described as benefit-to-harm derived from implementing the recommendation.
Exploring evidence-based practice barriers. Many simple, low-cost techniques have been known for decades to prevent SSIs.1 These include hand washing,7,8 preoperative clipping rather than shaving hair from the surgical site,8,44 using a sterile swab to remove subincision fluid postoperatively until drainage subsides,45 and avoiding gauze-type topical acute or chronic wound dressings.46-48 Despite ample evidence, research that includes a review of microbiologic diagnostic procedures for chronic wounds in Germany,49 a 7-week observational study of elective pediatric surgical cases at a US hospital,50 and a qualitative thematic analysis of institutional tools and protocols and transcripts of interviews with infection control supervisors at 7 Canadian hospitals51 shows guideline interventions for reducing chances of wound infection are inconsistently used.
To address this inconsistency of use, ICWIG TF members used brainstorming based on their experience to identify reasons for gaps between science and practice. In the course of their discussions, they realized that reducing wound infections would be feasible only if concerns and practices of each professional specialty involved in managing wound infection across settings were adequately served. As such, the ICWIG TF resolved to examine the construct validity of all evidence-based wound infection recommendations found in structured literature searches to ensure each final recommendation also was congruent with wound infection guidelines previously developed by individual specialties, such as infectious disease, dermatology, surgical, advanced practice nursing, or other specialists or by organizations devoted to specialized settings, such as acute care, home care, or military settings.
Literature review. Using recognized guideline development processes,52,53 the 19 members (ie, physicians, nursing professionals, and related doctoral candidates) of the ICWIG TF searched PubMed, Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from inception through November 30, 2013, including up to 400 of the most recent English publications using the search term wound infection combined with the search terms or synonyms risk factor, significant, diagnosis, prevention, treatment, or surveillance. Auxiliary related searches were conducted in Google Scholar to obtain full text and to expand evidence on specific recommendations as needed. Studies on parasitic infections or in vitro studies were excluded. The final step of selecting best available evidence from these and added searches supporting each ICWIG recommendation according to standardized criteria (listed in Table 2) was ongoing at the time of this publication.
Interdisciplinary relevance and construct validity. To ensure interdisciplinary ICWIG relevance for all specialties managing wound infection across all settings, ICWIG TF members verified that all unique major recommendations from 21 post-2000, interdisciplinary wound infection reviews, position papers, or guidelines were addressed by ICWIG recommendations identified by evidence found in the literature searches. Additionally, they evaluated each ICWIG recommendation’s construct validity by checking “Yes” if it was included in at least 1 interdisciplinary post-2000 wound infection guideline or review or “No” if not. Ensuring consistency with published interdisciplinary guidelines, reviews, and position papers of all ICWIG wound infection recommendations addressed Institute of Medicine (IOM) criteria52 for developing trustworthy guidelines while supporting each ICWIG recommendation’s capacity to harmonize wound infection practices for all members of interdisciplinary wound care teams across settings and specialties.
Content validation. ICWIG developers abstracted recommendations from evidence found in the initial literature searches, removed redundancy, and condensed all recommendations into a comprehensive list of 179 actionable recommendations. To ensure interdisciplinary clinical relevance of these recommendations, formal content validity54,55 was established by voluntary respondents to an online survey using judgment quantification to rate each recommendation’s clinical relevance on the 4-point scale shown in Table 2. Safety was estimated as SOR by each respondent rating the recommendation as “1” if more benefit than harm would be derived by implementing the recommendation or “0” if not as recommended by the IOM.52 Private ratings avoided potential bias from social pressures associated with consensus discussions. The content validation survey of recommendations compiled through November 30, 2013 was accessible online from December 1, 2013 through December 31, 2014. Invitations to complete the survey were published in major wound journals serving >40 000 readers and sent as eblasts to >5000 members of wound care societies in the United States, Europe, Asia, Australia, Canada, and Mexico.
Respondents downloaded the survey, completed it on their computers, then emailed the completed survey to an AAWC staff member who compiled all surveys into an Excel file for later analysis by an ICWIG TF member. In addition to the ratings described, the survey requested respondent credentials and practice demographics, along with their suggested changes or additions to the recommendations.
Updated literature searches. After the survey, the ICWIG TF conducted updated literature searches of PubMed and Google Scholar databases from December 31, 2014 through August 1, 2017, for the term wound infection combined with synonyms or derivatives of the terms reliable, valid, and significant, plus appropriate key words in each recommendation. Best available evidence from these and the prior searches currently is being reviewed, evaluated according to criteria in Table 2, added as appropriate supporting evidence to corresponding ICWIG recommendations, and abstracted into ICWIG evidence tables describing study patients, interventions, comparators, design, and outcomes of each of up to 5 best references supporting an ICWIG recommendation.
Updated interdisciplinary relevance and construct validity. The power of interdisciplinary teamwork in improving wound outcomes has been affirmed by expert consensus,9 randomized clinical trials,56 and longitudinal cohort studies.57,58 To ensure ICWIG interdisciplinary currency in empowering wound care team members to speak and act in harmony, ICWIG TF members evaluated a total of 27 interdisciplinary publications (literature reviews, position documents, or guidelines) to ensure 1) that each ICWIG recommendation was represented in at least 1 prior evidence-based published summary of wound infection recommendations, and 2) that every recommendation in these published summaries was addressed appropriately in the ICWIG. The construct validity check had been performed before the content validity survey for 21 publications59-80 and was repeated for 6 more recent publications accessed after completion of the last content validation survey.8,78,81-84
Data analysis and statistical methods. Relevance and benefit (SOR) content validity indexes (CVI) were calculated for each recommendation from all surveys returned as the percent of respondents rating that recommendation as 3 (relevant but needs minor improvement) or 4 (relevant and succinct) to their own clinical practice. A CVI of at least 0.75 is considered as having content validity,55 calculated as follows:
Relevance CVI = (number of 3 ratings + number of 4 ratings)/total N responding for the recommendation.
Benefit (SOR) validity was the percentage of respondents rating the recommendation’s implementation as 1 (beneficial) = (number of 1 ratings)/total N responding with a rating of 0 or 1 for the recommendation.
A 1-page ICWIG Checklist was compiled of the guideline recommendations with the highest CVI and SOR ratings (>0.75) for patient and wound assessment to diagnose and manage wound infection risk factors, wound infection prevention, and treatment.
In the final guideline (accessible at aawconline.org once best evidence is summarized and aligned with each recommendation), each recommendation will be displayed with its evidence rating from Table 2, up to its 5 best supporting references, CVI, and SOR.