Several years ago a drug company approached me to try to convince me to start using a new kind of "growth factor paste" to help speed up how fast wounds or ulcers on the feet and legs of diabetic patients would heal. They gave me the results of of a randomized controlled trial in which half the patients were given the real "growth factor paste" and the other half were given paste with no active ingredients in it. The growth factor paste was expensive and had some unpleasant side effects in some patients but on average wounds treated with the paste healed several days faster. The result was statistically significant (so was unlikely to be caused by random chance) but the improvement was only healing a few days faster over a several week period so I wasn't sure if it was worth the extra cost and risk of the side effects. Before deciding whether or not to recommend adding the new growth factor paste I got together with my colleagues. We picked out forty or fifty patients with lower leg ulcers in our clinics to see how fast we were healing them ourselves.
The results were striking. Even the placebo group in the research trial (the ones who weren't getting the growth factor paste) healed much faster than most of our cases! How could that be? Well, in the research trial all the patients were seen by expertly trained nurses who followed the same protocols when they treated patients with foot ulcers. They did a comprehensive assessment every time. They recorded exactly how long and broad and deep the wound was every time they saw the patient. They cut away the dead skin around the ulcers. They cleaned them and dressed the wounds the same way every time and they saw the patients back frequently until the ulcer was healing well. They taught the patients how to change their wound dressings and how to look for signs that things were not going well. Now when I looked at our own wound cases some of those good things happened some of the time but they didn't all happen every time. Sometimes a patient would be seen but the size of the ulcer was not recorded. Sometimes they were left to go too long before they were seen again. They might be seen by a different person the next time who, not knowing how big the wound had been the last time, didn't know if it was improving or getting worse. different doctors and nurses in different clinics used different approaches to how they treated wounds. No one was talking to each other or sharing their results and nothing was being tracked, so no-one could learn or improve.
So after discussing this with my colleagues we came to two conclusions. First, there was no point in adding expensive new growth factor paste onto a chaotic system where no two wounds were being treated the same way. Second, we needed to change the way we were treating our wounds. We needed to look at the published medical literature and visit wound care "Centers of Excellence" to learn the best way to treat wounds. We then needed to develop rules and expectations that used these good approaches and teach that to all of the doctors and nurses who treat patients with wounds. Everyone would follow these rules. Everyone would record their results and progress in the same way. We would share results with each other. We would learn together and keep improving.
So what happened? Once we put this new "evidence-based wound care system" in place and trained our doctors and nurses to do it the right way every time we started healing wounds much faster than we ever had before. We review results at every clinic every week. We coach people to improve. We share results with each other and change the "evidence-based protocols" whenever we find a new and better way to do something. When that change is made everyone makes that change and this becomes the new "standard approach" for managing wounds. The doctors and nurses are much happier with their work, now, take pride in how well they are doing, and more importantly, patients are getting their wounds healed faster and fewer of them are losing their legs.
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