Richard “Sal” Salcido, MD, EdD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia.
In this month’s continuing medical education (CME) activity (page 371), we benefit from the superb and sustained leadership typified by Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, ETN, MAPWCA, FAAN, and Sharon Baranoski, MSN, RN, CWCN, APN, DAPWCA, FAAN. The survey encompassed 8 years and includes 647 nursing colleagues, giving us robust data from which to draw conclusions. And, the study guides the way forward in implementing, measuring, and improving evidence-based practices and compliance of the requirements set by regulators.
The workforce management implications are illustrated by the demographics of the respondents; as the data indicate the majority of the wound care practitioners at the point of service continue to be licensed practical nurses/licensed vocational nurses and registered diploma nurses, with most of them having more than 2 decades of nursing practice. This gives significant credibility to the results of the survey. Let’s discuss a few of the survey questions.
Pressure Ulcer Staging
Pressure ulcer (PrU) staging is covered in question 13 of the survey. ”I can identify the 6 stages of PrUs in my patients.” The authors stated they were “intrigued by the drop in percentage of correct responses in the survey compared with 2005, when PrUs were categorized in 4 stages.” Although the authors rightfully address the discrepancies in answering this question, it could be that “the confusion about the stages” can be explained by the increased choices of qualitative descriptors, such as “unstageable/unclassified depth unknown, and suspected deep tissue injury.”
Unanswered Questions Remain: Turning Schedules, Question 8
The respondents were given a binary choice about turning schedules: To turn every 2 hours or not (true/false).
As a review, the basis for timed pressure duration curves were established and subsequently confirmed in animal models through quantitative verification of a hyperbolic pressure duration curve relationship.1–3 Some of this early animal research informed the practice of turning patients every 2 hours and was advanced in humans with the work of Reswick and Rogers4 in 1976. Forty years later, the 2-hour turning rule needs to be challenged with research. A dogmatic 2-hour-frequency turning schedule lacks the strength-of-evidence rating to draw scientific conclusions. In a recent, large multisite, randomized clinical trial, known as Turning for Ulcer ReductioN (TURN) Study,5 there was no difference in PrU incidence over 3 weeks of observations between those turned at 2-, 3-, or 4-hour intervals in this population of nursing home residents at moderate and high risk of developing PrUs using high-density foam mattresses when repositioning was done consistently and skin was monitored.5
For now, the best advice is to adhere to the National Pressure Ulcer Advisory Panel recommendations regarding the use of support surfaces and realize that turning our patients more frequently than not is important for PrU prevention.
Wound Cleansing: Question 19
Interestingly, the survey section about wound cleansing takes the scab off the elusive povidone-iodine toxicity debate. Most studies with povidone toxicity have been reported from “in vitro,” but some adverse “in vivo” reports of catastrophic toxicity are emerging in the surgical literature6–8; however, Ward et al9 insist “that the evidence against povidone is based on cytotoxicity in a cell culture environment (in vitro), which may not precisely reflect cellular toxicity, tissue toxicity, or wound-healing interference in an in vivo environment.”9 As the debate endures, some surgeons continue to support the use of povidone-iodine in orthopedic procedures.9
Wilkins and Unverdorben10 support the counterargument against using “hydrogen peroxide, sodium hypochlorite, acetic acid, alcohol, ionized silver preparations, chlorhexidine, polyhexanide/betaine solution, or povidone—iodine”—“the majority of which are locally toxic and of limited or no proven efficacy in enhancing wound healing.” The consensus of opinion is that these topical cleaning agents should not be routinely used.
The test of an excellent CME is that it provides teaching and learning, stimulates discussion, and explores a multifaceted view of the practice of wound care. The cohort participating in this study and the leaders conducting the study bring great credit to the wound care field.
Richard “Sal” Salcido, MD, EdD
1. Kosiak M. Etiology and pathology of ischemic ulcers. Arch Phys Med Rehabil 1959; 40: 62–9.
2. Husain T. Experimental study of some pressure effects on tissues, with reference to the bed-sore problem. J Pathol Bacteriol 1953; 66: 347–58.
3. Salcido R, Carney J, Fisher S. A reliable animal model of pressure sore development: the role of free radicals. J Am Paraplegia Soc 1993; 16: 61.
4. Reswick J, Rogers JE. Experience at Rancho Los Amigos Hospital with devices and techniques to prevent pressure ulcers. In: Kenedi R, Cowden J, Scales J, eds. Bedsore Biomechanics. London: University Park Press; 1976: 300.
5. Bergstrom N, Horn SD, Rapp MP, Stern A, Barrett R, Watkiss M. Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc 2013; 61: 1705–13.
6. Labbé G, Mahul P, Morel J, Jospe R, Dumont A, Auboyer C. Iodine intoxication after subcutaneous irrigations of povidone iodine [in French]. Ann Fr Anesth Reanim 2003; 22: 58–60.
7. Aiba M, Ninomiya J, Furuya K, Arai H, et al. Induction of a critical elevation of povidone-iodine absorption in the treatment of a burn patient: report of a case. Surg Today 1999; 29: 157–9.
8. Keating JP, Neill M, Hill GL. Sclerosing encapsulating peritonitis after intraperitoneal use of povidone iodine. Aust N Z J Surg 1997; 67: 742–4.
9. Ward WG Sr, Corey RM. To wash or not to wash: that is the question: commentary on an article by S. J. van Meurs, MD, et al: “Selection of an optimal antiseptic solution for intraoperative irrigation. An in vitro study.” J Bone Joint Surg Am 2014; 96 (4): e34–2.
10. Wilkins RG, Unverdorben M. Wound cleaning and wound healing: a concise review. Adv Skin Wound Care 2013; 26: 160–3.