Title: Pain relief strategies for dressing change in chronic wounds: a mixed-methods systematic review and survey of UK practice
Funder: Department of Health and Social Care

Abstract: Background to the problem_x000D_ A chronic wound (also called an ulcer) is an open sore in the skin that does not heal, or takes a long time to heal, and frequently comes back. Chronic wounds include pressure ulcers (bed sores), venous (vein-related) leg ulcers, and foot ulcers in people who have diabetes. Each of these chronic wounds has a different cause, has different symptoms, and is treated in different ways. However, one thing that is common for chronic wounds is the need for regular dressing changes, sometimes several times per week. These dressing changes are often a painful experience and can cause distress for the person having their dressing changed. _x000D_ For people living with chronic wounds in the United Kingdom (UK), most of the guidelines that are available to the National Health Service (NHS) focus on healing of the wound, rather than managing pain at dressing changed. As a result, there is currently no clear guidance on how people living with chronic wounds, their carer, or people who work in the NHS, should manage pain at dressing change. Whilst a number of ways of managing pain at dressing change are currently being used in the UK, the NHS do not currently know which is the best way to recommend._x000D_ Background to the research_x000D_ The National Institute for Health Research (NIHR) in the UK are asking for research to be undertaken about people living in the community with chronic wounds who experience pain at dressing change._x000D_ The first thing NIHR are asking for is a review of existing studies that look at different ways of managing pain at dressing change for chronic wounds and, from these studies, what might be the most effective and acceptable way of managing pain at dressing change for people with chronic wounds in the UK. This work involves experts in this type of research searching for studies that have been published on the topic of pain relief strategies for dressing change in chronic wounds, and looking at what the studies show. _x000D_ The NIHR also want know what pain relief strategies are currently being used in the UK and what are patients’, carers’ and healthcare professionals’ (people who work in the NHS) use and experience of these. This work involves undertaking a survey across the UK. Experts in this type of research will design a survey that will include questions about pain management at dressing change. The survey will ask what pain relief strategies are currently being used, along with peoples’ use and experience of these. _x000D_ The final thing the NIHR would like know is what would be an appropriate pain relief strategy (or strategies) which could be recommended for use in the community in the UK. For this, we will draw together results from the review of the published studies and the results from the UK survey, to help identify an appropriate pain relief strategy (or strategies) which could be used in the community in the UK._x000D_ Throughout the research we will ask people living with chronic wounds, carers and healthcare professionals in the UK to be involved. We will ask them what important things we should look for in our review of studies, and questions we should ask in our survey. Also, where results from our research might be best made available to people who want to see these._x000D_ We will make our results available in a number of ways, including publication in scientific journals and presentation at conferences. Also, as other formats that would fit with how patients and the public would want to see our results.

Lay abstract: RESEARCH QUESTIONS: For people living in the community with chronic wounds and experiencing pain at dressing change: i) What is the current evidence for strategies to relieve pain at dressing change? ii) What are the pain relief strategies currently used in UK practice and what are patients’, carers’ and healthcare professionals’ use and experience of these? iii) What are the requirements for an appropriate pain relief strategy, or strategies, which could be manualised, delivered and evaluated in the community?_x000D_ BACKGROUND: Pain during dressing change has been reported as the worst part of living with chronic wounds. However, currently in the UK there is no clear guidance on how patients, carers and healthcare professionals should manage wound-related pain at dressing change and, while various strategies are employed in practice, there is a need to evaluate available evidence underpinning their efficacy._x000D_ AIMS AND OBJECTIVES: The aim of the research project is to determine what strategies are currently being used in the UK. The research will seek users’ opinions on their effectiveness, and explore which strategies could be manualised for use in the community and other UK settings. The objectives will be to:_x000D_ 1) Undertake a mixed methods systematic review of the quantitative evidence on interventions for pain prevention and alleviation at dressing change. Also, qualitative evidence reporting of experiences of patients, carers and healthcare professionals; _x000D_ 2) Undertake a survey of current practice in the UK to document what is being used or not used for a variety of chronic wounds_x000D_ 3) Examine systems and processes underpinning interventions, and where contextual factors may influence implementation and outcomes using a logic model to draw together the different data sources._x000D_ 4) Identify pain relief strategies that could be manualised, delivered and evaluated in the UK community, and identify where evidence gaps exist._x000D_ METHODS: A mixed methods systematic review will be undertaken. A series of UK surveys of practitioners will be carried out, together with qualitative interviews with patients, healthcare professionals and carers in a sequential mixed methods design. A logic model will underpin exploration of intervention pathways across the data sources, in order to contextualise the review evidence and explore variation and consistency in current practice in order to recommend those strategies that could be manualised, delivered and evaluated in the UK community, and to identify evidence gaps to inform future research. The work will be informed by stakeholder and patient and public involvement at all stages to ensure relevance and co-development of outputs._x000D_ TIMELINES FOR DELIVERY: The project will take place over 24 months, with the systematic review in months 1 to 12, Ethics application and roll out of the UK survey in months 1 to 18, analysis of the UK survey results in months 19 to 21 and write up and dissemination in months 22 to 24._x000D_ ANTICIPATED IMPACT AND DISSEMINATION: The findings from this project will be shared with UK guideline developers and research funders to help inform clinical guidelines for pain management at dressing change of chronic wounds in the community and other UK settings; and identify evidence gaps for future research. Stakeholders will be involved in developing recommendations. We will develop a dissemination plan to identify who needs to hear about the research and how we will achieve reach and impact.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: SKIN;GENERIC HEALTH RELEVANCE