Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
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.
Tuesday, October 20, 2015
Best practice guidelines are designed to aid clinical decision making for specific clinical situations based on the best available evidence. There are 3 broad categories of evidence, including scientific findings, clinical or expert experience, and patient preference (considering clinical circumstances and healthcare resources available). Although randomized controlled trials and meta-analyses are considered the gold standard of evidence, qualitative studies are extremely valuable to answer questions about how people feel, what works in a specific situation, why things occur, and what patients prefer.
Standardized wound care plans often fail because they do not include patients’ preferences and their quality of life (QOL), which is defined as a general perception of well-being by an individual and the impact of a disease on people’s daily life. It is a subjective but dynamic construct that is influenced by emotions, beliefs and values, social context, and interpersonal relationships, which together account for its variability. A number of qualitative studies help us to understand patients’ perception of QOL. People who are living with chronic wounds describe the experience as isolating, debilitating, depressing and worrisome, all of which contribute to high levels of stress. Feeling embarrassed about the repugnant smell, fluid leakage from wounds and their bodies, people with chronic wounds may intentionally avoid social contacts and activities. Patients often feel detached and emotionally distant from their friends and families, rendering it difficult to maintain meaningful friendships and romantic relationships.
Patients with chronic wounds are frequently isolated and lack social support. The provision of wound care requires a systematized and holistic approach to address comorbid conditions and psychosocial issues, expertise that extends beyond local wound care, and dressing selection. A well-coordinated and interprofessional team approach is integral to the delivery of high-performance and evidence-based wound care services. Management of these ulcers involves a detailed examination and discussion with patients to adequately address their concerns.
Thursday, July 9, 2015
The use of a staging system to describe and document pressure ulcers (PrUs) continues to be a subject of debate since misuse and misinterpretation is common. There are a number of advantages and limitations of using the current staging system.
Let’s look at the Pros:
• Staging is a standardized language to describe and document PrUs based on tissue involvement.
• The stage of a PrU has been used to benchmark cost of care.
• There is evidence that mortality is related to advanced stages of PrUs.
Now, the potential Cons:
• There is a tendency to backstage and use the numerical classification systems to depict progression of healing.
• The staging category does not change even when the ulcer is healing. However, accurate staging is challenging if previous assessment of the wound, including the type of tissue damage, is not available.
• It is not easy to differentiate Stage I PrUs from moisture-associated skin damages and deep tissue injuries.
• Accurate identification of staging is less accurate when there is slough or yellow fibrin on the wound base.
• The staging system has poor prognostic value.
• Device-induced PrUs may initially present as a Stage I PrU, although deep tissue injury may have already occurred.
• Skin tears are often confused as PrUs.
By eliminating the current numerical classification system and documenting the partial-thickness and full-thickness depth, along with the appropriate physical findings (location, size, base, exudate, and margins), healthcare providers may prevent misleading communication. The National Pressure Ulcer Advisory Panel’s PrU guideline describes Stage II PrUs as partial-thickness wounds versus Stage 3 and 4 as full-thickness wounds.
What are your thoughts on this topic?
Thursday, March 19, 2015
Recently, we asked the question in our quick poll whether wounds should be packed or not. Sixty percent of you agreed that wounds should be packed versus 40% disagreed with the practice of wound packing. Wound packing had renewed debate in the wound care community. As healing occurs, keratinocytes or skin cells migrate from the wound edge to the center of the wound to promote granulation. For large ulcers with significant tissue deficit, the wound opening will decrease in size at a faster rate than the reduction in wound depth and size of wound tunneling/undermining. As such, there is always a risk that the opening may close or approximate before complete healing has occurred from the bottom; leaving a dead space underneath the newly formed skin. The space provides an ideal place for bacteria to proliferate potentially allowing an abscess to develop.
The purpose of packing is to prevent premature closure of the wound and abscess formation. However, opponents against wound packing had identified situations wherein packing material acts like a plug that prevent free flowing of wound drainage. Congested wound fluid increases that risk for wound infection. In addition, certain packing materials have a tendency to bunch up applying pressure and damaging fragile granulation tissue on the wound base surface. To determine whether to pack or not to pack a wound, clinicians should consider the purpose of packing, dressing materials, and the presence of tunnels. Shallow wounds usually do not require aggressive packing. Light packing is recommended for deep and large ulcers to ensure healing occurs from the bottom up. Some clinicians admonish using the term “packing,” which often conjures up the image of someone going on a vacation and jam-packing his or her suitcase. As one of my colleagues prudently instructed, remember to “fluff not stuff.”
Thursday, December 4, 2014
A systematic review is more than an overview of the literature germane to a topic. A systematic review usually follows a rigorous process to include a broad range of relevant studies that have been undertaken and provide a detailed critical appraisal and synthesis of the individual studies. Here are the key steps:
1. Identifying the research question: The purpose of the review is to address a clinical question using existing scientific evidence and knowledge. The question is the focus and will provide the direction for the review. For example: What is the body of knowledge relating to the management of venous leg ulcers?
2. Identifying relevant studies and information: To ensure inclusion of a substantial breadth and comprehensiveness of evidence, a team is usually assembled to perform a comprehensive literature search with the help of a librarian scientist. Depending on the type of review, a number of electronic databases will be searched. The review may include published or unpublished primary studies with or without an explicit study design, theses, commentaries, editorials, and the grey literature (information in electronic and print formats not controlled by commercial publishing and other relevant references retrieved from web search). It is important that key non-peer-reviewed journals are hand searched to identify articles that would not be indexed in electronic databases.
3. Study selection: The strength of a review lies in the depth and breadth of the evidence covered. The team will independently review each title and abstract of the literature search results to determine whether the paper should be included for more in-depth review. Explicit inclusion and exclusion criteria will be helpful.
4. Charting the data: The research team members will extract data from selected papers using a standardized abstraction form to document systematically the context of relevant information in each paper. Given the range of study designs, reviews, reports, and commentaries, data will include names of the authors, the purpose of the study/paper, types of participants, research methods used, study setting, theoretical framework, outcome and assessment details, authors’ conclusion, and implication to practice.
5. Collating, summarizing and reporting the results: A consistent approach to reporting the findings will allow comparisons across intervention types, as well as identify contradictory evidence and delineate gaps in the evidence. Analyzing of the data will involve a narrative or descriptive numerical summary and a thematic analysis.
Now you can appreciate the scholarship that is required to conduct a systematic review. Next time when you read a review paper, see if you can identify the key steps. Remember, not all reviews are the same. Reviews that did not describe and follow a precise methodology are subjected to serious bias problem.