Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Thursday, July 09, 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 04, 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.
Wednesday, September 10, 2014
Management of diabetic foot ulcers requires comprehensive and lifelong behavioral modifications that include regular foot care, exercise, dietary changes, smoking cessation, and frequent blood glucose testing. People with foot ulcers do not always wear appropriate footwear to protect their feet, wash their feet daily, or follow diet recommendations. Poor adherence is one of the determining factors contributing to chronic nonhealing foot ulcers and associated home care costs. Although traditional educational interventions to improve knowledge are necessary, they are rarely sufficient to change behaviors. Emerging evidence highlights a need to shift the chronic disease management paradigm to focus on patient engagement and self-management.
My colleagues and I have recently received funding from Queen’s University in Kingston, Ontario, Canada, and the Ontario government to develop a support group using social media (the Online Foot Club) for people with diabetic foot ulcers. Social media encompasses a variety of platforms that provide opportunities for multiple users to exchange experiences/information and provide support through multisensory communication. The purpose of the Online Foot Club is to promote chronic disease self-management and treatment adherence. According to a 2012 survey,1 61% of adult internet users searched online and 39% used social media to obtain health information. Not all information available on the internet, however, is credible. With the shifting attitude toward social media, there is a need for healthcare professionals to actively engage and support patients using communication technology creatively. The innovative use of social media has the potential to widen the access of health information and make contact with difficult-to-reach or isolated population because of their geographical location, cultural dispositions, and socioeconomic status.
Tell us how your healthcare facility or university is using social media to help educate and communicate with patients.
1. Fox S, Jones S. The Social Life of Health Information. 2009.
Last accessed September 10, 2014.
Monday, April 21, 2014
Wound infection and biofilm is one of the most exciting yet controversial topics in chronic wound management. Recent advances in the understanding of wound infection pathogenesis have generated tremendous interest in biofilm and how it is related to wound healing. Differentiation of critical colonization, deep wound infection, and biofilm is a challenging, but important, task. It is generally accepted that topical antimicrobial agents should be considered for localized wound infection and systemic agents are introduced for wound infection that involves soft tissue. Despite existing guidelines, only half of patients with diabetic foot ulcers received appropriate antibiotic therapy for the treatment of infection. Surgical site infection is a growing concern in the community. With the advent of a plethora of topical antimicrobial agents that have been developed in the last decades, clinicians are now challenged with decisions of when and what antimicrobial agents to use. According to results of the recent quick poll on this website, the majority of the readers agreed that general clinicians do not have adequate knowledge to manage wound infection. Researchers at Queen’s University School of Nursing in Kingston, Ontario, Canada recently surveyed 80 physicians and identified a significant knowledge gap in wound management, especially around wound infection and biofilm. There is a need to enhance the knowledge and build capacity for physicians to assess and treat wound infection and biofilms. It is very encouraging to observe that almost all respondents also acknowledged their roles in wound care and expressed a keen interest to further their knowledge.