Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.

Wednesday, April 12, 2017

The most recent National Pressure Ulcer Advisory Panel (NPUAP) update in 2016 introduced the term pressure injury to replace pressure ulcer.   According to the NPUAP, "a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue." (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages)

Since its inception, the new terminology has sparked impassioned discussion within the practice communities.  In our recent Quick Poll on this journal's website, we asked whether readers had espoused the term pressure injury in practice and only half of the respondents indicated in the affirmative.

There are polarized but not irreconcilable perspectives on whether the term "injury" should or should not be used.  According to the Merriam-Webster Dictionary, injury is defined as:  (1) an act that damages or hurts; or (2) violation of another's rights for which the law allows an action to recover damages.  Injury can be sustained either by accident or intention; obvious characteristics that will vary include permanence or transience; potential for grievous harm or not.  Even if the injury was caused by negligence or breach of duty, the responsible party is liable for payment of damages for the harm caused.

In keeping with the definition, pressure injury connotes damage to tissue due to pressure, but whether the injury is a direct result of an action or lack thereof is debatable.  Skin failure and changes at life's end may not be amendable to actions that are normally considered effective for the prevention of skin injuries due to significant physiological changes that accompany multisystem failure and circulation collapse.

The NPUAP points out that injury is a common term used to refer to several health conditions and medical diagnoses, such as acute brain injury, and it does not connote or assign blame.  Proponents for the use of pressure injury also highlight the added clarity and precision that the new terminology offers to the description of a Stage 1 pressure injury, which refers to intact skin with nonblanchable redness of a localized area usually over a bony prominence.  Calling this type of skin injury as ulcer is misleading. Besides, deep tissue injury is a term that is already well accepted and recognized.  Perhaps we should use injury for skin damages associated with moisture, venous insufficiency, arterial disease, and diabetes foot complications.

Thursday, February 2, 2017

Peripheral artery disease (PAD) is a common and disabling health condition affecting 20% of people over age 75. This disease is primarily caused by atherosclerotic changes in the arteries limiting normal blood flow to the lower extremities. As the disease progresses, insufficient oxygen and nutrients to the tissue can result in complications such as chronic leg pain, skin ulceration, gangrene, and eventually amputation. One of the most common and earliest manifestations of PAD is intermittent claudication; described as pain in a lower extremity muscle group (such as the buttock, thigh, and calf) that is elicited by exertion and relieved within a few minutes of rest.  Over time, pain may be elicited by minor exertion and become more frequent even at rest. There is evidence that two-thirds of people with mixed venous arterial leg ulcers experience moderate to severe pain daily.  As such, people with PAD are more likely to experience a loss of autonomy, disability, work impairment, emotional distress, and poor quality of life compared with individuals without PAD.

Ischemic pain is complex and caused by a multitude of mechanisms, including the lack of oxygen, accumulation of metabolic waste, reperfusion injuries, inflammation, nerve damage, vasospasm, trauma, and anxiety.  However, ischemic PAD is underrecognized, underdiagnosed, and therefore, undertreated.  Routine use of opiates could cause many adverse effects (such as drowsiness and confusion), but do not always provide adequate pain relieve. Although we recognize a need for a holistic approach to address ischemic pain, none of the existing guidelines addresses best practice for ischemic pain. This is an area that will benefit from interprofessional collaboration involving specialists in pain management, psychology, rehabilitation science, vascular medicine, and palliative care. 

Tuesday, November 1, 2016

I recently returned from the World Union of Wound Healing Societies (WUWHS) meeting in Florence, Italy.  Florence is a beautiful city and the meeting was an absolute success.  The WUWHS 2016 was supported by a large number of national and international "Sister Societies," all of whom come together every 4 years during the Congress of WUWHS. I had the opportunity to learn from many renowned wound care experts from around the world. Here are some of the highlights:

  • Wound pH meter for the assessment of wound healing.  Low pH is a predictor of wound healing.
  • Skin tears are common and the International Skin Tear Advisory Panel tool has been translated and validated in different languages. 
  • Vibration therapy has been used to treat pressure injury in Japan.
  • There are conditions that can mimic deep tissue injury. There is a need to develop better diagnostic criteria for deep tissue injury.
  • Biofilm is ubiquitous in chronic wounds.  Debridement is key to address wound biofilm.
  • Pyoderma gangrenosum is an auto-inflammatory disease and is often associated with endocrine disorders and diabetes.
  • Pyoderma gangrenosum has been documented in a number of syndromes including: PASH syndrome (pyoderma gangrenosum, acne, suppurative hidradenitis)  and PAPA syndrome (pyogenic arthritis, pyoderma gangrenosum, and acne)
  • Portable electrostimulation devices are used for patients with chronic venous leg ulcers.
  • Researchers from Germany presented on their successful use of film compression bandages for venous leg ulcers.
  • New surfactant dressing for wound debridement and biofilm management.
  • New consensus documents on pressure ulcer prevention, closed surgical incision management, local management of diabetic foot ulcers, understanding hydradenitis supprativa, and innovations in ard to heal wounds. Documents are available in PDFs in http://www.wuwhs2016.com/documents

Tuesday, February 9, 2016

​We recently had a quick poll asking your opinion about whether we need more wound care clinicians with graduate training, such as masters and doctorate degrees. To address this question, it is important to point out the difference between expert practitioner and advanced practice clinician in wound care. An expert practitioner is someone with an extensive background of experience in wound care. He or she may be very skilled at debriding calluses; applying negative pressure wound therapies, or using compression wraps and other special skills. An expert may also be able to recognize clinical patterns, grasp the context as a whole, and zero in on nuances that are important to help make appropriate clinical decisions. In general, an expert is able to respond to the clinical changes in an intuitive way. So why do we need graduate training?

Graduate education is designed to help learners to develop the ability to interpret and appraise research, synthesis complex information, and translate knowledge into practice. Wound care is more than hands-on practice. Advanced wound care is based on evidence and theories. An advanced practitioner follows a systematic process to plan, implement, and evaluate, and taking into account the organization culture and human factors. Wound care models based on inter-professional collaboration that provide education and psychosocial support have demonstrated to be efficacious in terms of improving patient outcomes. An advanced practitioner utilized a number of tools to examine individual and systemic barriers that need to be addressed to optimize clinical outcomes. Ideally, a wound specialist should have expertise in wound management, as well as advanced skills in research utilization, program development, and quality improvement.

Monday, November 30, 2015

Pressure ulcers (PrUs) are monitored and tracked by legal and regulatory bodies as a benchmark for performance, risk, and safety. Accepting the notion that most PrUs are preventable, the prevalence of PrUs remains considerably high in North America.

My colleagues and I published a prospective cohort study using population level administrative data that involved a total number of 203,035 unique patients across the 4 healthcare settings: acute care (AC), long-term care (LTC), home care (HC), and complex care (CC).  A complex care environment provides continuing, medically complex, and specialized services to people who have long-term illnesses or disabilities typically requiring skilled, technology-based care (such as ventilators) not available at home or in long-term-care facilities.  Between 2010 and 2013, the annual prevalence of PrUs ranged from 8.2 to 9.1; CC had the highest prevalence of PrUs (22.6%), followed by AC (10.2%), LTC (8.4%), and HC (3.7%).  The average PrU incidence over the 4 years studied ranged from 1.4% in HC to 7.0% in CC.

I find it interesting that 28.3% of residents who developed PrUs had a recent hospital admission and they developed PrUs 1 week after they returned to long-term care. In addition to PrUs, we also examined other skin conditions.  The most common skin condition was skin tears/abrasions, which was documented in 26% of long-term-care residents. Benchmarking the prevalence of PrUs as a quality indicator allows goal setting and comparison of performance over time and among healthcare sectors. With a growing emphasis on optimizing safety and reducing risk within the healthcare system, analysis of aggregated administrative data is necessary to identify care gaps and vulnerable populations to whom necessary resources should be allocated.