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WOUND

Wound Literature Review 2009

Journal of Wound, Ostomy and Continence Nursing: July/August 2010 - Volume 37 - Issue - p S2-S19
doi: 10.1097/WON.0b013e3181e408b9
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General Concepts

W1 TITLE: Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary

AUTHORS: O'Malley G, Dominici P, Giraldo P, et al

SOURCE:Society for Academic Emergency Medicine 2009; 16(5):470–473

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

  • Forty-eight subjects with abscesses less than 5 cm in diameter were randomly allocated to packing versus nonpacking following incision, drainage, and irrigation.
  • Subjects received trimethoprim-sulfamethoxazole ibuprofen and an opioid analgesic. Subjects recorded Visual Analog Pain scores and the amount and type of pain medication used to comfortably control pain twice daily. They were also examined 48 hours by a physician who had not initially seen the patient. This physician evaluated the need for further intervention and assessed erythema, induration and fluctuance. A second, similarly blinded physician repeated the evaluation and assessment.
  • Thirty-four out of 48 subjects (71%) returned after 48 hours; none were assessed as requiring additional treatment or admission. Subjects randomized to management without packing reported less pain and used fewer pain medications when compared to those managed packing.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Results of this study suggest that packing is not required for management of simple abscesses following incision and drainage.

W2 TITLE: Collagenase for Enzymatic Debridement: A Systematic Review

AUTHORS: Ramundo J, Gray M

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(6S):S4–S11

ARTICLE TYPE: Systematic Review of Literature

DESCRIPTION/RESULTS:

  • Authors review studies involving collagenase published between 1960 and 2009. Limited studies were identified, but findings support collagenase as being more effective than an inactive ointment in debriding necrotic tissue.
  • Existing evidence suggests that collagenase is a selective debrider, and rendered more effective when covered with a damp dressing.
  • Data indicate that collagenase is almost totally inactivated by cadexomer iodine and is partially inactivated by silver dressings with the exception of ionic silver, which causes minimal inhibition.
  • In the studies reviewed, the only reported adverse effect was mild and transient stinging in a minority of patients.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This review provides support for the use of collagenase in debridement and provides specific guidelines to enhance efficacy.

W3 TITLE: Collagenase Santyl Ointment: A Selective Agent for Wound Debridement

AUTHORS: Shi L, Carson D

SOURCE:Advances in Skin and Wound Care 2009;22(12 Suppl):S12–S16

(Edited and produced by JWOCN)

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • Authors describe mechanisms by which collagenase provides selective debridement and implications (e.g., there is very low risk of bleeding because collagenase does not attack fibrin).
  • Authors review in vitro data that suggests that collagenase and the breakdown products produced by debridement may promote cell migration.
  • The authors also provide useful information regarding compatibility with other dressings. Pigment- complexed PVA (Hydrofera Blue) and collagen-based dressings are compatible, cadexomer iodine and nanocrystalline silver dressings are incompatible, and ionic silver dressings have a mild inhibitory effect.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides clinically relevant information regarding the mechanisms of action for collagenase and clinical implications and guidelines for use.

W4 TITLE: Wound Areas by Computerized Planimetry of Digital Images: Accuracy and Reliability

AUTHORS: Mayrovitz H, Soontupe L

SOURCE:Advances in Skin and Wound Care 2009; 22(5):222–229

ARTICLE TYPE: Pilot Study

DESCRIPTION/RESULTS:

  • Assessment of a wound's progress in healing is dependent, in part, on accurate measurements. While dimensions and surface area are commonly accepted approaches for measuring wound size, the ratio of surface area to perimeter has been reported as a more accurate indicator of progress toward healing, because it is unaffected by initial wound area and reflects the wound's closure rate.
  • This pilot study sought to determine the validity and reliability of digital photography plus computerized planimetry in measurement of wound surface area, and to determine the surface area to perimeter ratio.
  • Twenty senior student nurses used digital photography and a software program providing computerized planimetry to obtain measurements on 6 test wounds of various shapes and degrees of irregularity.
  • Mean error rates averaged <3% for all test wound measurements.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Findings of this study provide support for objective determination of wound surface area and surface area to perimeter ratio, and illustrate the benefits of digital photography and computerized planimetry in wound assessment. The article provides helpful data for providers in outpatient wound clinics and others who need to accurately track progress toward healing.

W5 TITLE: Swab Cultures for Diagnosing Wound Infections: A Literature Review and Clinical Guideline

Author: Bonham P

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(4):389–395

ARTICLE TYPE: Systematic Literature Review

DESCRIPTION/RESULTS:

  • The author reviewed evidence regarding use of swab cultures for diagnosis of a wound infection. Databases were searched for research studies, meta-analyses, systematic or critical reviews, guidelines and expert opinion published between 1950 and 2008.
  • Several studies suggest that quantitative swab cultures, when performed correctly, are a reasonable alternative to tissue biopsies (considered the gold standard for obtaining a quantitative culture) in identification of causative organisms and determination of antibiotic sensitivities.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a summary of the evidence base for swab cultures, and a research-based guideline for obtaining swab cultures (Levine's technique, i.e., swab 1 cm2 viable tissue following flush with normal saline).

W6 TITLE: Honey-Based Dressings and Wound Care: An Option for Care in the US

Author: Pieper B

Source: Journal of Wound, Ostomy and Continence Nursing 2009;36(1):61–67

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The author identifies evidence pertaining to the use of honey as a topical agent to promote healing of chronic wounds, reviews its mechanistic actions, and summarizes implications for WOC nursing practice.
  • The author points out that randomized controlled studies are needed to provide definitive recommendations for use of medicinal honey in wound care.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article serves as a good review of current theories and evidence regarding use of honey in wound care and would be beneficial for any practitioner who is contemplating use of honey.

W7 TITLE: Efficacy of a Skin Tear Education Program: Improving the Knowledge of Nurses Practicing in Acute Care Settings

AUTHORS: McTigue T, D'Andrea S, Doyle-Munoz J, Forrester DA

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(5):486–492

ARTICLE TYPE: Prospective Quasi-experimental Education Intervention Study

DESCRIPTION/RESULTS:

  • The researchers measured the knowledge base of acute care nurses regarding skin tears and evaluated the efficacy of an online educational program designed to improve knowledge of (1) predisposing factors, (2) identification and assessment using the Payne-Martin Classification System and (3) preventive care, treatment and documentation.
  • The educational intervention was a web-based program available for over 4 months on the intranet service for two affiliated hospitals. Following completion of the program participants were better able to identify and correctly assess skin tears. Participation in the intervention enabled nurses to achieve greater knowledge of the various categories of skin tears and treatment guidelines.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • In this study, web-based training was effective in improving nurses' knowledge of skin tear identification, assessment, classification, differentiation, and treatment. Web-based learning can be an effective tool to supplement or replace more traditional methods of education for nurses.

W8 TITLE: The Winning Nutrition Team

Author: Collins N

SOURCE:Ostomy Wound Management 2009;55(1):10

ARTICLE TYPE: Informational

DESCRIPTION/RESULTS:

  • This short article clarifies the expertise and contribution of various nutritional team members (e.g., RD, CDE, CNSD, LD, CDM) and their role in wound management.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article is a good reference for any provider who is either developing or supporting the existence of a comprehensive interdisciplinary team including nutritional team members.

W9 TITLE: A Prospective, Descriptive Study to Identify Microbiological Profile of Chronic Wounds in Outpatients

AUTHORS: Basu S, Panray TR, Singh TB, Gulati AK, Shukla VK

SOURCE:Ostomy Wound Management 2009;55(1):14

ARTICLE TYPE: Prospective, Descriptive Study Report

DESCRIPTION/RESULTS:

  • The microbiologic characteristics of 52 chronic wounds, mostly on the lower extremities of 50 outpatients, were described via culture. Participants' average age was 52.5 years (range 18-90).
  • Forty-five out of 52 wound cultures grew one organism, 5 grew 2 organisms, and 2 grew nothing. The most common organisms were Pseudomonas aeruginosa (21), and E. coli (8). Eighteen percent of the pathogens were multi-drug resistant organisms (MDRO).
  • The authors hypothesize that the high prevalence of MDRO was associated with widespread and frequently inappropriate use of antibiotics in wound care.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The findings of this study illustrate the importance of addressing all local and systemic factors affecting wound healing before administering systemic antibiotics. These findings are especially beneficial for providers seeking data supporting more cautious and thoughtful use of antibiotics.

W10 TITLE: The Impact of Noncontact, Nonthermal, Low-Frequency Ultrasound on Bacterial Counts in Experimental and Chronic Wounds

AUTHORS: Serena T, Lee SK, Lam K, Attar P, Meneses P, Ennis W

SOURCE:Ostomy Wound Management 2009;55(1):22

ARTICLE TYPE: Prospective Descriptive Study

DESCRIPTION/RESULTS:

  • The authors report findings of a four-part study addressing the effect of nonthermal, low frequency ultrasound on bacterial load and indicators of wound infection. Part 1 was an in vitro study to determine depth of ultrasound penetration. Part 2 was an in vitro study describing the effect of low frequency, nonthermal ultrasound on a number of common organisms. Part 3 described results of an in vivo model to determine impact of each of the following on bacterial counts: ultrasound, silver dressings, and water moistened gauze. Part 4 was an in vivo study that described the effect of low frequency ultrasound on bacterial counts in chronic wounds of 11 patients.
  • Results: Phase 1 revealed that low frequency ultrasound penetrated to a greater depth than sham. Phase 2 demonstrated that one ultrasound application reduced Pseudomonas aeurginosa by 33%, E. coli by 40%, and Enterococcus faecalis by 27%, but had minimal impact on Staphylococcus aureus including MRSA. Sham treatment had no impact on bacterial counts. The third study found that both ultrasound and silver dressings reduced bacterial loads, while loads increased with sham ultrasound and water-moistened gauze. In Phase 4, 15 organisms were isolated, including Staphylococcus aureus, Acinetobacter baumannii, three strains of Pseudomonas (stuartii, mirabilis, aeruginosa), three strains of beta-hemolytic strep (G, B, A), and E. coli. The mean pre-treatment organism count was 4 × 107 CFU/mL and the post ultrasound count was 2 × 107CFU/mL.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • These four studies together describe the potential benefits of noncontact low-frequency ultrasound on bacterial counts and suggest that therapy may be beneficial in chronic wound management. The authors discuss the concept of bacterial balance, not sterility, in the wound bed and its positive impact on wound healing.

W11 TITLE: A Retrospective Cohort Study of Factors That Affect Healing in Long-term Care Residents With Chronic Wounds

AUTHORS: Takahashi PY, Kiemele LJ, Chandra A, Cha SS, Tagonski PV

SOURCE:Ostomy Wound Management 2009;55(1):32

ARTICLE TYPE: Retrospective Cohort Study

DESCRIPTION/RESULTS:

  • Medical records were reviewed over an eight-year period, which included 397 residents with chronic wounds. The authors looked at multiple potentially associated factors including age, gender, diabetes, stroke, peripheral vascular disease, depression, dementia, degenerative arthritis, falls and peripheral neuropathy.
  • Factors associated with failure to heal within 6 months included low hemoglobin and more than one wound.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides support for a comprehensive approach to wound care and suggests that low hemoglobin may play a greater role in failure to heal than previously appreciated. While more study is needed, wound clinicians should assess hemoglobin and should remember that low levels may affect the ability to heal.

W12 TITLE: Standardization of Wound Photography Using the Wound Electronic Medical Record

AUTHORS: Rennert R, Golinko M, Kaplan SD, Flattau A, Brem H

SOURCE:Advances in Skin and Wound Care 2009;22(1): 32–38

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • The authors describe the Wound Electronic Medical Record, including its advantages, benefits and specific considerations in product selection and training for involved personnel.
  • Specific guidelines for assuring accurate calculations of wound area using tracings of digital photographs, and strategies to reduce interobserver variability are discussed.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article is an excellent resource for a clinician or facility establishing protocols for wound photography, with or without incorporation into the electronic medical record.

W13 TITLE: Using Leptospermum Honey to Manage Wounds Impaired by Radiotherapy: A Case Series

AUTHORS: Robson V, Cooper R

SOURCE:Ostomy Wound Management 2009;55(1):38

ARTICLE TYPE: Case Series

DESCRIPTION/RESULTS:

  • Four patients were followed for radiotherapy-associated dermatitis; all were treated with medical honey. The authors report that all patients had measurable progress in healing.
  • The article also provides a sound review of the pathophysiology of radiation dermatitis and implications for management.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Findings from this case series suggest that medicinal honey may be beneficial for patients with radiation dermatitis.

W14 TITLE: Nutrition 411—The Facts About Vitamin C and Wound Healing

Author: Collins N

SOURCE:Ostomy Wound Management 2009;55(3):8

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • This short article describes the role of Vitamin C in wound healing; includes recommended daily requirements, food sources, signs of deficiency, and clinical implications.
  • Since Vitamin C is water soluble, there is a need for daily intake and patients should be encouraged to ingest foods rich in Vitamin C on a daily basis
  • Supplementation is not usually necessary unless a deficiency is suspected; however, supplementation should be considered for patients with wounds (especially if there are concerns regarding adequacy of dietary intake). Contraindications include history of kidney stones and iron overload conditions.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides concise and current guidance regarding the role of Vitamin C in wound healing.

W15 TITLE: Nutrition 411—The Nutritional Melting Pot: Understanding the Influence of Food, Culture and Religion on Nutrition Interventions for Wound Healing

AUTHORS: Collins N, Friedrich L, Postauer ME

SOURCE:Ostomy Wound Management 2009;55(5):14

ARTICLE TYPE: Informational

DESCRIPTION/RESULTS:

  • This article reviews Hispanic, Asian, African and American food intake patterns and religious dietary practices. A detailed table of the general characteristics of various diets is included.
  • The authors emphasize the importance of providing culturally appropriate nutritional choices in order to meet individual's nutritional needs. A mnemonic to guide the provider (Attitude, Beliefs, Content, Decision-making style, and Environment) is recommended.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article reminds providers that “one size does not fit all” when considering nutritional counseling, and identifies specific guidelines for culturally appropriate nutritional recommendations.

W16 TITLE: Nutrition 411—Vitamin D Deficiency: Shining New Light on the Sun Nutrient

AUTHORS: Collins N, Spaulding-Albright N

SOURCE:Ostomy Wound Management 2009;55(4):14

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • This short article discusses Vitamin D and how the lack of sun exposure and the overuse of sunscreen have produced a Vitamin D-deficient society. The authors state that approximately 58% to 70% of the population is deficient.
  • The authors discuss Vitamin D's impact on wound healing, its role in promoting host resistance to infection, the effects of deficiency, and guidelines for assuring adequate intake, including indications for supplementation.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides current information on the role of Vitamin D in healing, the prevalence of Vitamin D deficiency, and implications for wound care.

W17 TITLE: Five Millennia of Wound Care Products—What Is New? A Literature Review

Authors: Moues CM, Heule F, Legerstee R, Hovius SER

SOURCE:Ostomy Wound Management 2009;55(3):16–32

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • The authors review the history of wound care and wound care products.
  • They also provide a list of wound care organizations and current wound care guidelines.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides an excellent resource for any provider who is doing a presentation on the history of wound care. The list of organizations and guidelines provides a useful guide to available resources.

W18 TITLE: A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial Burden

AUTHORS: Woo KY, Sibbald RG

SOURCE:Ostomy Wound Management 2009;55(8):40–48

ARTICLE TYPE: Cross-sectional Validation Study

DESCRIPTION/RESULTS:

  • The authors compared results of swab cultures with clinical signs of infection as reflected by the mnemonics NERDS (for critical colonization) and STONEES (for invasive infection) in 112 patients with wounds. Swab culture results were reported as yielding scant, light, moderate, or heavy growth.
  • The authors found that scant or light growth correlated positively to indicators of critical colonization (NERDS), while moderate or heavy growth correlated positively to indicators of infection (STONEES). They also found that cultures were positive for all wounds with any 3 signs of infection.
  • Authors note potential benefit of a validated tool that provides guidance as to when to treat wounds for infection, and point out that treatment should be culture-based to assure use of the appropriate antibiotic.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This study provides evidence that the mnemonics NERDS and STONEES can be used to help clinicians identify infected wounds that require culture and antibiotic therapy. Further research is needed to replicate the results of this study.

W19 TITLE: Nutrition 411—To Feed or Not to Feed: Nutrition Considerations at the End of Life

AUTHORS: Collins N, Spaulding-Albright N

SOURCE:Ostomy Wound Management 2009;55(9):12

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • An overview of changes in nutritional and fluid needs at end of life is discussed, along with implications for clinical practice.
  • The authors discuss common issues associated with nutrition at end of life, such as impact of reduced metabolic rate, dementia, and misconceptions regarding effects of reduced nutrient intake. Guidelines for tube placement and tube feeding are presented.
  • The article includes a list of resources that would be of assistance to clinicians in dealing with these issues

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a helpful overview of nutrition and hydration issues at the end of life, and would be beneficial for any clinician managing patients at end of life.

W20 TITLE: Use of Honey for Wound Healing (Research Forum)

AUTHORS: Langemo D, Hanson D, Anderson J, et al

SOURCE:Advances in Skin and Wound Care 2009;22(3): 113–118

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • Reported benefits of Manuka (leptospermum) honey in wound care are described. Of particular interest is a description of a study that found statistically significant reduction in pH of wound bed, and further observed that the most acidic wounds also showed the greatest progress toward healing.
  • Another randomized controlled trial is described that found that Manuka honey was more effective in reducing the volume of slough in necrotic wounds than a hydrogel when treated over a 4-week period.
  • The authors also summarize reports from posters on honey presented at a wound care symposium, including a pilot study, suggesting that wound healing may be accelerated when managed by honey-impregnated alginate dressings, as compared to non-impregnated alginate dressings.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article summarizes evidence supporting honey as a viable option in management of chronic wounds.

W21 TITLE: Implementing Wound Care Guidelines: Observations and Recommendations From the Bedside

Author: Lloyd-Vossen J

SOURCE:Ostomy Wound Management 2009;55(6):50–55

ARTICLE TYPE: Commentary

DESCRIPTION/RESULTS:

  • The author addresses barriers to effective wound care and notes that the availability of evidence-based guidelines is only part of the solution. The author goes on to argue that the clinician's understanding of the treatment plan is a second essential component of effective management.
  • The influence of wound care terminology is discussed and the author opines that many terms commonly used by wound specialists (such as alginate) have no meaning to non-specialist or lay care providers. Formulation of a more descriptive nomenclature, such as “absorbing dressing” rather than alginate, is advocated.
  • The author also recommends evaluation of available guidelines based on their “use-ability” and developing additional guidelines for non-specialist of lay care providers.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article is a helpful reminder of barriers commonly encountered when implementing wound care guidelines and when providing patient and family education.

W22 TITLE: “Measurement Monday”: One Facility's Approach to Standardized Skin Impairment Documentation

AUTHORS: Stewart S, Bennett S, Blokzyl A, et al.

SOURCE:Ostomy Wound Management 2009;55(12):49–53

ARTICLE TYPE: Quality Improvement Initiative

DESCRIPTION/RESULTS:

  • The authors describe a 2-year quality improvement project designed to increase accuracy of wound assessment and documentation.
  • At baseline only 41% of patient charts were found to contain complete documentation of wound assessment and care; the authors reported they were able to increase the portion of complete documents to 61.5% following implementation of their quality improvement initiative.
  • The authors then describe implementation of additional quality improvement measures such as a standardized form for weekly measurements, and designation of a standard day for wound assessment (Measurement Monday). Following these measures, 85% of charts were deemed “complete.”

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article describes several innovative strategies successfully used by one facility to improve documentation of wound care.

W23 TITLE: Cost-effectiveness of Negative Pressure Wound Therapy for Postsurgical Patients in Long-term Acute Care

AUTHORS: de Leon J, Barnes S, Nagel M, et al.

SOURCE:Advances in Skin and Wound Care 2009;22(3): 122–127

ARTICLE TYPE: Retrospective Chart Review

DESCRIPTION/RESULTS:

  • The authors compared wound-related outcomes of patients with surgical wounds managed with negative pressure wound therapy (NPWT) to patients managed with moist wound healing (defined as non-gauze dressings including alginates, hydrofibers, hydrocolloids, collagen, silver dressings, growth factors) alone. All wounds with necrotic tissue were debrided prior to initiation of either NPWT or moist wound healing.
  • The average length of treatment with NPWT was 24.3 days; once a healthy bed of granulation tissue was established and all underlying anatomical structures were covered, patients managed by NPWT were “crossed over” to moist wound healing.
  • Patients managed by NPWT followed by moist wound healing showed significantly faster reduction in wound size when compared to those managed by moist wound healing interventions alone.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This retrospective study suggests that NPWT may promote more rapid granulation of clean surgical wounds when compared to topical therapy with moist wound healing products alone. A prospective randomized controlled trial is needed to provide more definitive evidence of the role of NPWT in promoting rapid granulation of surgical wounds.

W24 TITLE: A Randomized Crossover Investigation of Pain at Dressing Change Comparing Two Foam Dressings

AUTHORS: Woo K, Coutts P, Price P, Harding K, Sibbald G

SOURCE:Advances in Skin and Wound Care 2009;22(7): 304–310

ARTICLE TYPE: Randomized Controlled Trial With Crossover

DESCRIPTION/RESULTS:

  • Thirty-two patients were randomly allocated to receive either silicone adhesive foam dressing or an adhesive hydrocellular polyurethane foam dressing for 2 visits and then switched to the alternate foam dressing for 2 visits. The research setting was 2 outpatient clinics and 1 acute care facility. Patients were asked to rank the severity of pain before, during, and after dressing changes. Wound status was assessed as well.
  • Patients managed with the silicone foam dressing had significantly lower pain scores prior to and during dressing removal, reduced maceration of adjacent skin, less necrotic tissue, and a greater percentage of new epithelium than patients managed with the polyurethane foam dressing.
  • Study limitations include a small sample size, absence of blinding and use of non-validated techniques to assess wound and periwound status.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Silicone adhesive dressings may reduce pain, wound trauma, and maceration; an adequately powered randomized controlled trial with adequate blinding is needed to provide a more definitive comparison of these foam dressings.

W25 TITLE: Venous Thromboembolism Prophylaxis and Wound Healing in Patients Undergoing Major Orthopedic Surgery

AUTHORS: Snyder B, Waldman B

SOURCE:Advances in Skin and Wound Care 2009;22(7): 311–315

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • Thrombin may affect wound healing through several mechanisms: activation of inflammatory response; chemotaxis for fibroblasts, epithelial cells, and endothelial cells; and growth factor production. The authors advocate careful consideration of the effects of various anticoagulants on thrombin when selecting agents for DVT prophylaxis.
  • They further note that Factor Xa inhibitors (fondaparinux) block formation of new thrombin but do not disrupt platelet function and do not interfere with existing thrombin.
  • Data indicating that orthopedic patients managed with fondaparinux are less likely to experience prolonged wound drainage is discussed.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article points out that wound care providers should be aware that agents for DVT prophylaxis may also affect wound healing.

W26 TITLE: A Randomized, Double-Blind, Placebo-Controlled Trial to Determine the Effects of Topical Insulin on Wound Healing

AUTHORS: Rezvani O, Shabbak E, Aslani A, Bidar R, Jafari M, Safarnezhad S

SOURCE:Ostomy Wound Management 2009;55(8):22–28

ARTICLE TYPE: Randomized Double-Blind, Placebo-Controlled Trial

DESCRIPTION/RESULTS:

  • Forty-five consecutive outpatients with acute and chronic extremity wounds were randomly assigned to two treatment groups. One group was treated with insulin crystal in solution (1 cc/10 cm2) sprayed onto the wound twice daily, and a second group was treated with a placebo spray containing no insulin. Following application of the spray, wounds were allowed to dry for 30 minutes and covered with sterile gauze.
  • Wound healing rates for subjects receiving the insulin spray were significantly better than rates in the control group. No adverse effects attributed to the intervention were reported.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This small study needs to be replicated with moist wound healing as the comparator (standard) intervention. Nevertheless, results suggest that topical insulin may promote healing in lower extremity wounds.

W27 TITLE: Prevention and Management of Skin Tears

AUTHORS: LeBlanc K, Baranoski S

SOURCE:Advances in Skin and Wound Care 2009;22(7): 325–331.

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • The authors review multiple aspects of skin tears including risk factors, the Payne-Martin Classification System, preventive interventions (hydration, moisturization, protective garments, avoidance of tape on fragile skin, gentle handling), and management options, including non-adherent or silicone adhesive dressings and skin glue.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article contains valuable information for anyone who needs to update their protocols and/or staff education programs on skin tears.

W28 TITLE: Anatomical and Physiological Basis for Corneotrophic Care of the Skin

AUTHORS: Gurll N, McCord D

SOURCE:Advances in Skin and Wound Care 2009; 22(9):402–411

ARTICLE TYPE: Integrative Review

DESCRIPTION/RESULTS:

  • The authors provide a detailed description of the layers and structures of the skin, and the physiology of epidermal cell mitosis. The discussion also elucidates potential negative effects of occlusive dressings on wound healing as well as their positive effects on scar formation.
  • Parameters of epidermal penetration (molecules <500 dalton units are thought to be able to penetrate—most allergens involved in contact dermatitis are<500 d in size) are described, and potential benefits of skin care products containing flavonoids and antioxidants<500 d in size such as olivamine are discussed.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides insight into the mechanisms by which allergens penetrate the skin and factors theorized to determine which topical agents can exert harmful or beneficial effects. The overview of the anatomy and physiology of the skin and effects of occlusive dressings is also valuable.

W29 TITLE: Interventional Patient Hygiene for the Wound Care Professional

AUTHORS: McGuckin M, Torress-Cook A

SOURCE:Advances in Skin and Wound Care 2009;22(9): 416–420

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The incidence and impact of hospital-acquired infections and role of hand hygiene, oral hygiene, and skin hygiene in reducing risks of hospital-acquired infections is discussed.
  • Potential benefits of use of a chlorhexidine gluconate (CHG) pre-moistened washcloth for preoperative skin disinfection and the potential application for routine bathing in high risk settings are discussed.
  • The authors also address benefits of disposable bathing systems as opposed to soap and water bathing.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article summarizes data regarding disposable bathing systems including one incorporating CHG.

W30 TITLE: Hypothesis for the Formation and Maintenance of Chronic Wounds

Author: Mansbridge J

SOURCE:Advances in Skin and Wound Care 2009;22(4): 158–160

ARTICLE TYPE: Commentary

DESCRIPTION/RESULTS:

  • The author proposes that compromised recruitment of leukocytes to the wound bed, resulting in bacterial overgrowth and biofilm formation may contribute to impaired wound healing. He further proposes that this compromised recruitment may be attributable to senescence of the cells that normally produce the chemoattractants for leukocytes (e.g., dermal fibroblasts). He speculates that this senescence may be caused by prolonged exposure to reactive oxygen species promoted by underlying disease.
  • The author acknowledges that these relationships are speculative, but argues that prompt debridement of any necrotic tissue and aggressive management of critical colonization/biofilms is indicated regardless of the veracity of the underlying mechanisms proposed in this article.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The argument that moving wounds through the inflammatory phase as quickly as possible via debridement and management of bacterial loads (e.g., use of sustained release antimicrobial dressings for patients at high risk for wound infection and chronicity) is sound. Additional research is needed to confirm the mechanisms advocated in this interesting commentary.

Pressure Ulcers

W31 TITLE: The Nursing Process and Pressure Ulcer Prevention: Making the Connection

AUTHORS: Magnan M, Maklebust J

SOURCE:Advances in Skin and Wound Care 2009;22(2): 83–92

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • Pressure ulcer prevention from the perspective of the nursing process (assessment, planning, intervention, evaluation) is reviewed, with focus on matching preventive measures addressing the individual's specific risk factors.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a comprehensive review of the measures critical to an effective pressure ulcer prevention program, and helps to “tie all the pieces together.”

W32 TITLE: Wound Pain (Research Forum)

AUTHORS: Langemo D, Hanson D, Thompson P, Hunter S, Anderson J

SOURCE:Advances in Skin and Wound Care 2009;22(6): 255–258

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • Factors contributing to wound pain are reviewed, along with its impact on quality of life. The authors emphasize the importance of assessing wound pain via a validated tool; followed by implementation of local interventions such as nonadherent dressings, management of exudate, and topical analgesics, as well as systemic measures such as analgesics administered according to an accepted algorithm. The authors suggest using the WHO ladder for cancer pain, or Senecal's modification of this ladder that has been adapted for wound pain.
  • The authors point out that use of atraumatic dressings (hydrogels, hydrofibers, alginates, and soft silicone dressings) emerged as the most important strategy for minimizing wound pain in a recent study by the European Wound Management Association; the study is discussed in detail.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a concise overview of current knowledge regarding the pathology, prevention, and management of wound pain.

W33 TITLE: Pressure Ulcer Awareness and Prevention Program: A Quality Improvement Program Through the Canadian Association of Wound Care

AUTHORS: Orstead H, Rosenthal S, Woodbury M

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(2):178–183

ARTICLE TYPE: Quality Improvement Initiative Report

DESCRIPTION/RESULT:

  • The Canadian Association of Wound Care (CAWC) funded a study to determine the extent of pressure ulcers in Canada and discovered that the mean prevalence rate was 26% across all healthcare facilities.
  • The CAWC then created a continuous quality improvement program known as the Pressure Ulcer Awareness and Prevention Program (PUAP), the program was designed to support a culture shift from emphasis on pressure ulcer treatment to a primary focus on prevention. The testing, revision and implementation of the program in various Canadian healthcare facilities is described.
  • The authors report up to a 57% reduction in the prevalence and 71% reduction in pressure ulcer incidence in facilities using the PUAP.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

W34 TITLE: Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers

Author: WOCN Society

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(4):378–381

ARTICLE TYPE: Position Statement

DESCRIPTION/RESULTS:

  • The position statement outlines WOCN's position on avoidable and unavoidable pressure ulcers. It also provides an overview of pressure ulcer prevention, summarizes supportive statements from the literature about risk identification and prevention protocols, and makes recommendations for further research, guideline development and implementation of evidence-based prevention interventions.
  • Conclusion is that some pressure ulcers may be unavoidable, but the focus for all clinicians should be on prevention.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a summary of current literature regarding avoidable versus unavoidable pressure ulcers and reinforces the importance of an aggressive and comprehensive prevention program.

W35 TITLE: Pressure Ulcer Management in the Acute Care Setting: A Response to Regulatory Mandates

AUTHORS: Walsh N, Blanck A, Barrett K

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(4):385–388

ARTICLE TYPE: Quality Improvement Initiative Report

DESCRIPTION/RESULTS:

  • The authors sought to reduce baseline pressure ulcer prevalence from 12.8% in 2006 to less than 7%, the national benchmark for pressure ulcer prevalence at that time.
  • A comprehensive quality improvement program was initiated that included administrative support, research-based risk assessment tool, intensive staff education, and updated products for prevention, including skin care products and pressure redistribution surfaces for at-risk populations including OR.
  • Pressure ulcer incidence decreased from 12.8% in 1st quarter of fiscal year 2007 to 0.6% in fourth quarter of 2008.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides excellent guidelines for establishment of a comprehensive and effective pressure ulcer prevention program.

W36 TITLE: Are Pressure Redistribution Surfaces or Heel Protection Devices Effective in Preventing Heel Pressure?

AUTHORS: Junkin J, Gray M

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(6):602–608.

ARTICLE TYPE: Systematic Literature Review (Evidence-Based Report Card)

DESCRIPTION/RESULTS:

  • The authors reviewed evidence concerning whether pressure redistribution surfaces or heel protectors are effective for preventing heel ulcers.
  • Existing evidence suggests that pressure redistribution surfaces vary in their ability to prevent heel ulcers; there is insufficient evidence to determine which if any surfaces are optimal for this purpose.
  • There is insufficient evidence to determine whether or not commercial heel elevation devices provide better protection than properly positioned pillows.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Expert opinion supports heel elevation as the most effective approach to protection against pressure, shear, and friction. Additional considerations include prevention of foot drop and rotation of the leg, ability to wick away moisture, ability to clean the device, stability of the device despite patient movement, and ability to protect the heel without adding pressure to other surfaces on the foot.

W37 TITLE: Successful Heel Pressure Ulcer Prevention Program in a Long-term Care Setting

Author: Lyman V

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(6):616–621

Article Type: Quality Improvement Initiative Report

DESCRIPTION/RESULTS:

  • The authors sought to evaluate the impact of a standardized protocol (including a heel elevation device) and intensive staff education on incidence of heel pressure ulcers in a long-term care facility.
  • Prior to the intervention, the facility's incidence rate for heel pressure ulcers was 2.1%-5.0%.
  • The program targeted patients with low Braden Scale scores (18 or less) and one of the following 7 comorbid conditions: diabetes, peripheral vascular disease, CVA, hemiparesis, low albumin, hip fracture, total knee replacement, vasopressor therapy. The revision included the use of a heel protector (Prevalon Heel Protector; Sage Products), daily application of a moisturizer to the heels, and Q 8 hour assessment of heel skin status.
  • Following the intervention there was a 95% reduction in incidence and an estimated cost savings between $12,400 and $1,048,400.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides documentation that a comprehensive prevention program can dramatically reduce the incidence of heel pressure ulcers, and emphasizes the importance of consistent offloading along with routine skin care and assessment.

W38 TITLE: Braden Scale Risk Assessment and Pressure Ulcer Prevention Planning

AUTHORS: Magnan M, Maklebust J

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(6):622–634

ARTICLE TYPE: Descriptive Study (Secondary Data Analysis)

DESCRIPTION/RESULTS:

  • The researchers evaluated the relationship between scores on Braden subscales and nurses' selection of 10 commonly used best-practice measures for pressure ulcer prevention.
  • Nurses' selection of preventive interventions was influenced by subscale scores and the combinations of risk factors as reflected by subscale scores. As risk scores decreased (and level of risk increased), nurses predictably increased their selection of preventive measures.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This data analysis provides evidence that accurate risk assessment promotes increased attention to preventive measures. It reinforces the importance of staff development programs focused both on accuracy of pressure ulcer risk assessment and aggressive preventive measures.

W39 TITLE: Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper

AUTHORS: Pieper B, Langemo D, Cuddigan J

SOURCE:Ostomy Wound Management 2009;55(2):16

ARTICLE TYPE: Integrative Review/NPUAP White Paper

DESCRIPTION/RESULTS:

  • A comprehensive review of current literature related to pressure ulcer pain is provided. Fifteen articles published between 1992 and 2008 are reviewed that address types of pain, pathology of pain, pain assessment, and strategies for prevention/treatment.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article emphasizes the prevalence and significance of pressure ulcer pain and provides helpful guidelines for its assessment and management.

W40 TITLE: Developing and Evaluating Outcomes of an Evidence-Based Protocol for the Treatment of Osteomyelitis in Stage IV Pressure Ulcers: A Literature and Wound Electronic Medical Record Database Review

AUTHORS: Rennert R, Golinko A, Yan A, Flattau A, Tomic-Canic M, Brem H

SOURCE:Ostomy Wound Management 2009;55(3):42–53

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The authors review the literature on osteomyelitis and conclude that up to 32% of all full-thickness pressure ulcers are complicated by osteomyelitis. They discuss its impact and summarize current research related to its diagnosis and management in the setting of a Stage IV pressure ulcer.
  • The article also introduces a seven-step protocol that was developed based on this literature review.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This review provides a clear evidence-based pathway for diagnosis and management of osteomyelitis.

W41 TITLE: Deep Tissue Injury From a Bioengineering Point of View

AUTHOR: Gefen A

SOURCE:Ostomy Wound Management 2009;55(4):26–36

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • This review addresses suspected deep tissue injury and pressure ulcer development from a pathophysiologic perspective.
  • The author analyzes each component of current descriptions of Suspected Deep Tissue Injury (SDTI); this author suggests that more data are needed to establish clinical validity of current definition.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • While the 2007 NPUAP staging system is most current, it clearly remains a “work in progress.” This article challenges providers to consider the new category of SDTI from a pathophysiologic perspective and to conduct additional studies to establish its validity.

W42 TITLE: Reducing Pressure Ulcer Prevalence Rates in the Long-term Acute Care Setting

AUTHORS: Milne CT, Trigilia D, Houle TL, DeLong S, Rosenbloom D

ARTICLE TYPE: Quality Improvement Initiative Report

SOURCE:Ostomy Wound Management 2009;55(4):50–59

DESCRIPTION/RESULTS:

  • The authors reviewed the literature review but found no articles regarding pressure ulcer prevention in the LTAC setting.
  • They report on implementation of a pressure ulcer prevention bundle in a 108-bed LTAC that incorporated administrative support, development of a reporting structure, and a “prevention and management infrastructure” including pressure redistribution surfaces, nutritional management, and wound care.
  • A substantial reduction in pressure ulcer incidence following implementation of the pressure ulcer prevention bundle (from 41% to 4.2%) was reported.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article suggests that a pressure ulcer prevention program is feasible and effective when implemented in the long-term acute care setting.

W43 TITLE: The Role of Interventional Patient Hygiene in Improving Clinical and Economic Outcomes

AUTHORS: Carr D, Benoit R

SOURCE:Advances in Skin and Wound Care 2009;22(2): 74-78

ARTICLE TYPE: Quality Improvement Initiative Report

DESCRIPTION/RESULTS:

  • Authors report on process improvement study with 3 areas of focus: evidence-based skin hygiene/bathing using disposable washcloths impregnated with pH-balanced cleanser and moisturizer; proactive management of incontinence through use of disposable washcloths impregnated with dimethicone and use of internal bowel management system for incontinence involving high volume liquid stool; and education of unlicensed personnel regarding skin inspection and indicators for RN notification.
  • They demonstrated a marked reduction in pressure ulcers (7% to 0%) and marked increase in knowledge level of unlicensed personnel.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Results of this quality improvement initiative demonstrate that an interventional hygiene program that relies on unlicensed personnel is both feasible and has the potential to reduce pressure ulcer incidence.

W44 TITLE: Results of the 2008-2009 International Pressure Ulcer Prevalence™ Survey and a 3-Year, Acute Care, Unit—Specific Analysis

AUTHORS: VanGilder C, Amlung S, Harrison P, Meyer S

SOURCE:Ostomy Wound Management 2009;55(11):39–45

ARTICLE TYPE: Cross-sectional Retrospective Study

DESCRIPTION/RESULTS:

  • Prevalence and incidence of 96,000 patients (including 86,932 patients from acute care setting) is reported.
  • Facility acquired prevalence rates (incidence rates) were 6% in 2008 and 5% in 2009.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This survey provides current data on pressure ulcer incidence rates, especially in acute care settings. It provides critical data for benchmarking and suggests that incidence rates may be decreasing, possibly due to an increased focus on prevention. Additional data are needed to determine whether this decline truly represents the gradual decline owing to an increased focus on prevention.

W45 TITLE: The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper

AUTHORS: Dorner B, Posthauer M, Thomas D, NPUAP

SOURCE:Advances in Skin and Wound Care 2009;22(5): 212-221

ARTICLE TYPE: Integrative Review Article/NPUAP-EPHAP White Paper

DESCRIPTION/RESULTS:

  • This article focuses on evidence related to nutrition and hydration for pressure ulcer prevention and management, and the nutritional recommendations from the NPUAP/EPUAP International Guidelines for Pressure Ulcer Prevention and Treatment.
  • The authors review of types of nutritional compromise, impact of tissue injury and cytokine release on metabolism and GI function (anorexia, muscle wasting, reduced nitrogen retention, and impaired synthesis of albumin).
  • Validated tools for screening for nutritional compromise (MiniNutritional Assessment Form and Malnutrition Universal Screening Tool) are identified, and a rationale for their use (as opposed to exclusive reliance on visceral protein markers albumin and prealbumin), which are affected by multiple factors other than nutritional status.
  • The authors summarize nutrients critical to tissue repair including protein requirements, micronutrients (Vitamin C, zinc, and copper), and clarifies areas where definitive recommendations cannot be made based on current data (supplementation with glutamine and L-arginine). They point out that zinc supplementation should be limited to situations in which there are signs of deficiency, and that high-dose or prolonged zinc supplementation is contraindicated owing to potential interference with copper absorption.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides an excellent review of current guidelines for nutritional assessment and interventions for patients with pressure ulcers. The authors challenge our reliance on lab values as the sole basis for nutritional assessment.

W46 TITLE: Skin Care and Pressure Ulcers

AUTHOR: Dealey C

SOURCE:Advances in Skin and Wound Care 2009;22(9): 421-428

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • This article include a review of factors that may affect risk of pressure ulcer development by altering cutaneous response including dehydration, maceration, exposure to repeated periods of ischemia followed by reperfusion, shear, and possibly friction. They argue that further research is needed to determine whether friction does indeed play a role in pressure ulcer development.
  • NPUAP definitions for pressure, friction, and shear are reviewed and the rationale for a shift from stage or grade to category is discussed.
  • They also argue that skin tears, tape burns, IAD, maceration, and excoriation should not be classified as Stage/Category II lesions.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a useful reference for updated NPUAP and EPUAP revised systems for categorizing pressure ulcers.

W47 TITLE: Detection of Skin Erythema in Darkly Pigmented Skin Using Multispectral Images

AUTHORS: Sprigle S, Zhang L, Duckworth M

SOURCE:Advances in Skin and Wound Care 2009;22(4): 172-179

ARTICLE TYPE: Pilot Study for Validation Trial

DESCRIPTION/RESULTS:

  • The authors discuss our limited ability to detect Stage I pressure ulcers and suspected deep tissue injuries in patients with darkly pigmented skin, thus compromising our ability to provide appropriate early interventions for these individuals.
  • This pilot study explored feasibility of an imaging system with simple hardware and inexpensive filters to enhanced detection of erythema in persons with dark skin tones.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This study reminds clinicians that detection of Stage I pressure ulcers and suspected deep tissue injuries remains difficult in patients with darkly pigmented skin. While technology is being developed to improve accuracy in assessment of darkly pigmented skin, at present we must rely on careful inspection and palpation.

W48 TITLE: Annual Checkup: The CMS Pressure Ulcer Present-on-Admission Indicator

AUTHORS: Lyder C, Ayello E

SOURCE:Advances in Skin and Wound Care 2009;22(10): 476-484

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • A historical review of the basis for nonpayment decisions related to facility-acquired pressure ulcers, and shift in CMS payment philosophy (from third party payer to value-based purchaser) is provided.
  • Three new hospital-acquired conditions to be added to nonpayment list effective October 2009 are discussed: 1) surgical site infection following bariatric or orthopedic procedures; 2) deep vein thrombosis and pulmonary embolism following total knee or total hip replacement, and 3) extreme derangement in blood glucose levels.
  • The authors cite provocative statistics suggesting an 80% increase in pressure ulcer incidence over the last 13 years, with device-related pressure ulcers accounting for 9.1%.
  • Current ICD-9 codes for pressure ulcers are reviewed. The authors state that DTI should be documented as unstageable (707.25).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The authors provide an excellent review of the current status of the CMS initiative to reduce or eliminate payment for potentially preventable conditions, with specific information and suggestions for reducing facility-acquired pressure ulcers.

W49 TITLE: Reducing the Incidence of Pressure Ulcers in Nursing Home Residents: A Prospective 6-Year Evaluation

AUTHOR: Tippet AW

SOURCE:Ostomy Wound Management 2009;55(11): 52-58

ARTICLE TYPE: Longitudinal Observational Study

DESCRIPTION/RESULTS:

  • Authors sought to determine the sustainability of a facility-wide program designed to reduce pressure ulcer incidence.
  • Key elements in their prevention strategy included critical analysis of current practice and outcomes, formation of an interdisciplinary team, development of simple prevention protocols, selection of therapeutic pressure redistribution surfaces; and mandatory staff training.
  • Sustained reductions in pressure ulcer incidence were primarily attributed to three factors: facility commitment, strong leadership, and use of evidence-based protocols.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides another useful description of a pressure ulcer prevention protocol. The importance of administrative support to ensure such a program is sustainable is emphasized.

W50 TITLE: North Carolina Wound Nurses Examine Heel Pressure Ulcers

AUTHORS: Clegg A, Kring D, Plemmons J, Richbourg L

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(6):635–639

ARTICLE TYPE: Prospective Descriptive Study

DESCRIPTION/RESULTS:

  • The researchers described factors associated with and physical characteristics of patients experiencing heel ulcers. WOC nurses in eight different facilities (acute care, long-term care, and home care) participated in study.
  • Factors associated with development of heel pressure ulcers included advanced age, nutritional compromise, high body mass index, low Braden Scale scores, and multiple comorbid conditions including diabetes, systemic infection, end stage renal disease, and peripheral arterial disease.
  • Over half of the patients had palpable pedal pulses; 19% of the ulcers were classified as suspected deep issue injury, and 45% were classified as full thickness.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides insight into potential risk factors for heel ulcer development, and emphasizes the importance of heel ulcer prevention programs.

W51 TITLE: Reducing Hospital-Acquired Pressure Ulcers

AUTHORS: Chicano G, Drolshagen C

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(10):45–50.

ARTICLE TYPE: Quality Improvement Initiative Report

DESCRIPTION/RESULTS:

  • The authors report their experience with a pressure ulcer prevention initiative in a 25-bed intermediate care unit.
  • Analysis of practice revealed inconsistencies in identification of patients at risk, integration of preventive measures into the plan of care, and documentation of care provided.
  • Three-phase process improvement plan initiated that included measures to improve accuracy of skin assessment and documentation and risk assessment and documentation, introduction of triggers in the electronic documentation system that linked preventive measures to risk scores, implementation of protocols for twice daily removal of compression stockings, and updates to existing guidelines for skin and wound care. Implementation of the program led to only one hospital-acquired pressure ulcer in a 12-month period.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article summarizes results of a unit specific prevention program and provides insights into essential elements of a prevention program.

W52 TITLE: Pressure Ulcers in Pediatric Patients With Spinal Cord Injury: a Review of Assessment, Prevention, and Topical Management

AUTHORS: Wu S, Ahn C, Emmons K, Salcido R

SOURCE:Advances in Skin and Wound Care 2009;22(6): 273-284

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The authors provide review spinal cord injuries in pediatric population and its impact on pressure ulcer risk.
  • They also describe currently available pediatric risk assessment tools (Braden Q, Neonatal Skin Risk Assessment Scale, and Glamorgan), and principles of assessment (to include new tools for detecting Stage 1 ulcers in darkly pigmented skin).
  • Guidelines for management in the pediatric population, including considerations for dressing selection, such as avoidance of hydrogels for infants in warmers or incubators, avoidance of calcium alginates in neonates and premature infants due to potential for calcium and sodium absorption, and cautious use of silver in large wounds due to potential for systemic absorption are discussed.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a concise and comprehensive review of pressure ulcer assessment and management in pediatric patients with SCIs; it also provides very helpful guidelines for dressing selection in the pediatric population.

Lower Extremity Ulcers

W53 TITLE: Infected Venous Leg Ulcers: Management With Silver-Releasing Foam Dressing

AUTHORS: Dimakakos E, Katsenis K, Kalemikerakis J, et al

SOURCE:Wounds 2009;21(1)

ARTICLE TYPE: Randomized Controlled Trial

Description/Results

  • The authors report a randomized controlled trial comparing forty subjects randomly allocated to 9 weeks of therapy with a nonadhesive silver foam (Contreet Ag foam, Coloplast) versus a nonadhesive foam (Biatain, Coloplast). Outcomes measures were progress toward healing and pain reduction.
  • Dressings were changed twice a week with the same cleansing method and wrapped with short stretch compression bandages. Pain was evaluated at each visit.
  • Eighty-one percent of subjects randomized to the nonadhesive silver foam achieved wound closure in 9 weeks and 100% were reported as pain-free. Forty-eight of those allocated to the nonadhesive foam achieved wound closure at 9 weeks and 62% were deemed pain free.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Results of this study suggest that use of a nonadherent foam dressing with ionic silver may decrease pain and time to healing for patients with venous ulcers when compared to a nonadherent foam dressing without silver.

W54 TITLE: Cadexomer Iodine: An Effective Palliative Dressing in Chronic Critical Limb Ischemia

AUTHOR: Williams R

SOURCE:Wounds 2009;21(1)

ARTICLE TYPE: Retrospective Chart Review

DESCRIPTION/RESULTS:

  • The outcomes of 11 subjects with peripheral arterial disease (PAD), chronic critical limb ischemia (CCLI), and wounds on the distal lower extremities who were treated with daily applications of cadexomer iodine and weekly or biweekly outpatient wound clinic visits were retrospectively reviewed.
  • Seven subjects temporarily healed. At 18 months, two subjects underwent proximal amputations, four required revascularization and distal amputations, one was lost to follow-up, and 4 avoided amputations. None of the wounds developed wet gangrene.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • These findings suggest that cadexomer iodine may be beneficial for wounds associated with PAD and CCLI, especially among individuals who refuse amputation or for whom amputation is associated with an increased risk of morbidity and mortality.

W55 TITLE: Granulocyte-Colony Stimulating Factors as Adjunctive Therapy for Diabetic Foot Infections (Cochrane Review)

AUTHORS: Cruciani M, Lipsky BA, Mengolic C, de Lalla F

SOURCE:The Cochrane Collaboration 2009, Issue 3

ARTICLE TYPE: Systematic Literature Review and Meta-analysis

DESCRIPTION/RESULTS:

  • The researchers sought to evidence concerning use of Granulocyte-colony Stimulating Factors (G-CSF) on resolution of infection and wound healing in patients with diabetic foot ulcers.
  • Five randomized controlled trials enrolling 167 subjects with diabetic foot infections (infected ulcers, cellulitis, osteomyelitis, and/or deep abscesses) were reviewed and a meta-analysis of pooled data was reported.
  • Limitations of this meta-analysis were identified that included small sample sizes in the five trials and lack of standardization in “usual care.”
  • G-CSF did not significantly influence time to resolution of infection or time to wound healing. G-CSF did reduce the likelihood of surgical intervention (including amputation) and length of hospitalization.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • G-CSF may be an emerging treatment option for patients with diabetic foot infections; more research is needed to clearly identify patients most likely to benefit.

W56 TITLE: The Prediction of Wound Healing Outcomes Using Skin Perfusion Pressure and Transcutaneous Oximetry: A Single-Center Experience in 100 Patients

AUTHORS: Lo T, Sample R, Moore P, Gold P

SOURCE:Wounds 2009;21(11):310–315

Article Type: Quasi-experimental Comparison Cohort Study

DESCRIPTION/RESULTS:

  • One hundred subjects with chronic leg ulcers caused by chronic venous insufficiency (49%), peripheral arterial disease (15%), diabetes (35%), or unspecified etiology (1%) were non-randomly assigned to skin perfusion pressure (SPP) measurements obtained via an inflatable pressure cuff with an embedded laser Doppler sensor versus TcPo2 measurements for prediction of wound healing. A value of ≥ 30 mm Hg was used for both methods to predict healing.
  • SPP had a slightly higher positive predictive value as compared to TcPo2 (0.91 vs 0.88). Limitations to the use of each method were discussed; the authors report that SPP measures are not affected by edema, anemia, callus, or wound location.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The results of this study suggest that SPP is feasible and results are comparable to TcPo2 for measurement of healing potential in patients with chronic leg ulcers. The technology is available in the US but not widely used.

W57 TITLE: What's New in Lower-Extremity Arterial Disease? WOCN's 2008 Clinical Practice Guideline

AUTHORS: Bonham P, Flemister B, Goldberg M, Crawford P, Johnson J, Varnado M

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(1):37–44

ARTICLE TYPE: Systematic Literature Review

DESCRIPTION/RESULTS:

  • The authors provide a synopsis of the primary recommendations from the updated 2008 Guideline for Management of Wounds in Patients with Lower Extremity Arterial Disease.
  • Article summarizes the major recommendations from the LEAD guideline for assessment, interventions, patient education and risk-reduction strategies (e.g., currently recommended medications include cilostazol, statins, aspirin, and clopidogrel).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The article provides a comprehensive review of the current recommendations for management of patients with LEAD. The guideline can be obtained from the WOCN Web site http://http://www.wocn.org or by calling the WOCN National Office toll-free number: 1:888–224-9626.

W58 TITLE: The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and Leg Care Model

AUTHORS: Woo K, Sibbald RG

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(2):184–191

ARTICLE TYPE: Comparison Cohort Study

DESCRIPTION/RESULTS:

  • The authors evaluated an organized pain management approach using the Wound Associated Pain (WAP) Model in subjects with chronic leg and foot ulcers (wound bed preparation, systematic assessment and management of pain, and consistent attention to patient concerns). One hundred eleven subjects with chronic leg and foot ulcers were evaluated.
  • Using the WAP model, the authors demonstrated a reduction in average pain scores from 6.3 at week 0 to 2.8 at week 4 (using an 11-point numerical scale) and also demonstrated improved wound healing outcomes.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Results of this study suggest that a treatment of a wound incorporating the WAP model is associated with both reduction in pain during treatment and improved wound healing outcomes.

W59 TITLE: A Retrospective Study of High-Voltage, Pulsed Current as an Adjunctive Therapy in Limb Salvage for Chronic Diabetic Wounds of the Lower Extremity

AUTHORS: Burdge JJ, Hartman JF, Wright ML

SOURCE:Ostomy Wound Management 2009;55(8):30–38

ARTICLE TYPE: Retrospective Chart Review

DESCRIPTION/RESULTS:

  • Outcomes of 30 patients with diabetes mellitus and 45 chronic wounds were retrospectively reviewed. Management included complete evaluation with A1C and ankle brachial index measurements, counseling regarding smoking cessation, debridement of necrotic tissue, cultures of all wounds and antibiotics for infected wounds, and strict instructions regarding offloading/ non-weight bearing. In addition, patients received high-voltage, pulsed current (HVPC) stimulation two to three times weekly.
  • Thirty-five of 45 wounds (78%) closed and 10 failed to heal. One patient with a single wound required a transmetatarsal amputation, and four patients with five wounds required below the knee amputation. One wound deteriorated due to a necrotic tendon and 3 remained under treatment.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This study suggests that HVPC may be beneficial in the management of chronic lower extremity ulcers in patients with diabetes mallitus.

W60 TITLE: Diabetic Foot Ulcers (DFU)—Effects on Quality of Life (QOL), Costs, and Mortality and the Role of Standard Wound Care and Advanced-Care Therapies in Healing: A Review

AUTHORS: Snyder RJ, Hanft JR

SOURCE:Ostomy Wound Management 2009;55(11):28–38

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The authors review current literature regarding the effects of diabetic foot ulcers on morbidity, mortality, and quality of life. They also review literature regarding healing rates, use of advanced therapies, and associated costs.
  • Their discussion includes guidelines for management of diabetic foot ulcers focusing on standards published by the Wound Healing Society in 2006.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides an excellent synopsis of the impact of diabetic foot ulcers on morbidity/mortality and quality of life, and 2006 Wound Healing Society guidelines for management.

W61 TITLE: The Relationship Between Hemoglobin A1C Values and Healing Time for Lower Extremity Ulcers in Patients With Diabetes

AUTHORS: Markuson M, Hanson D, Anderson J, et al

SOURCE:Advances in Skin and Wound Care 2009;22(8): 365-372

ARTICLE TYPE: Retrospective Descriptive Correlational Study

DESCRIPTION/RESULTS:

  • Retrospective data from 63 patients including demographics, comorbidities, wound size at initial presentation and at last evaluation, and A1C at time of initial wound presentation and at evaluation closest to healing is reviewed.
  • Patients with lower extremity ulcers were found to have a high incidence of comorbid conditions including hypertension, coronary artery disease, and renal disease; 79.4% had peripheral vascular disease.
  • Sixty-two percent of the ulcers healed; the average time to healing was 133 days. HgbA1C at time closest to closure did not consistently correlate to healing: 44% healing rate for patients with A1C levels < 7%; 90% healing rate for patients with A1C 7%–10%; 100% for those with A1C > 10% (only 2 patients in this group). Smokers were less likely to heal when compared to non-smokers.
  • The recurrence rate was 40%.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Findings suggest that diabetic foot ulcers can be healed with aggressive management, even among individuals with multiple comorbidities including vascular disease. Further research is needed to determine the correlation between A1C levels, day-to-day glycemic control as measured by blood glucose levels, and wound healing.

W62 TITLE: The ABCs of Skin Care for Wound Care Clinicians: Dermatitis and Eczema

AUTHORS: Woo K, Sibbald G

SOURCE:Advances in Skin and Wound Care 2009;22(5): 230-236

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • The authors review the pathology, clinical manifestations, and management of dermatitis and eczema.
  • They also discuss the incidence of acquired contact allergic dermatitis in leg ulcer patients (51%–78%), common allergens for wound patients (lanolin, balsam of peru and fragrances, cetylsterol alcohol, neomycin, preservatives commonly found in creams, and latex), differentiation between humectants and lubricants, and relative potency of commonly used steroid preparations. Guidelines for treatment include recommendations for use of weak or moderate potency agents for face and body folds and moderate to strong potency agents for the extremities and trunk.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This is a beneficial resource for the wound clinician caring for patients with lower extremity ulcers and patients with dermatitis; of particular benefit is the list of common allergens and guidelines for use of topical steroids.

W63 TITLE: Peripheral Arterial Disease Among Substance Abusers in Drug Treatment

AUTHORS: Pieper B, Kirsner R, Templin T, Birk T

SOURCE:Advances in Skin and Wound Care 2009;22(6): 265-272

ARTICLE TYPE: Research Report: Cross-sectional Descriptive Study

DESCRIPTION/RESULTS:

  • The authors administered several validated tools and performed limited physical examinations in a group of 640 patients managed in 10 methadone clinics. Data analysis included stratification of findings based on age, gender, ethnicity, and history of drug abuse.
  • The authors report that 16.7% of participants had peripheral arterial; associated factors included female gender, smoking, and poor attitude toward physical activity.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Former drug users are now aging and may represent a high risk group for PAD. Interventions to reduce the incidence of PAD should be implemented, including smoking cessation programs and programs to encourage walking, which has been shown to improve calf muscle utilization of oxygen.

Burns, Skin Cancer, and Atypical Ulcers

W64 TITLE: Time-Related Concordance Between Swabs and Biopsy Samples in the Microbiological Assessment of Burn Wounds

AUTHORS: Salehifar E, Khorasani G, Ala S

SOURCE:Wounds 2009;21(3):84–88

ARTICLE TYPE: Prospective Cross-sectional Study

DESCRIPTION/RESULTS:

  • One hundred fifty-six samples (78 swab and 78 biopsies) were taken from 39 burn patients with partial and full thickness burns on days 7 and 14 after admission. The purpose of this study was to compare swab versus biopsy samples for monitoring microbiological isolates.
  • The researchers reported 87.1% agreement between swab and biopsy samples on day 7 and 66.6% agreement on day 14.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Study findings suggest that swab cultures are appropriate during the first week of treatment. Biopsy samples may be justified in patients who remain in the burn unit longer than a week.

W65 TITLE: Cardiovascular Health for Patients With Psoriasis: A Précis for Front-Line Clinicians

AUTHORS: Federman DG, Shelling ML, Prodanovich S, Gunderson CG, Kirsner RS

SOURCE:Ostomy Wound Management 2009;55(5):38–47

ARTICLE TYPE: Integrative Literature Review

DESCRIPTION/RESULTS:

  • Psoriasis is a common autoimmune process that has been associated with hypertension, diabetes, obesity, and recently a higher risk of myocardial infarction.
  • Authors point out that further studies are needed to verify the correlation between psoriasis and increased risk of myocardial infarction, but emphasize that providers and patients need to be aware of the current evidence and the implications for monitoring.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides important information regarding the link between psoriasis and increased risk of myocardial infarction; this is important information for providers caring for individuals with psoriasis.

W66 TITLE: Skin Cancers and Wounds in the Geriatric Population: A Review

AUTHOR: Snyder RJ

SOURCE:Ostomy Wound Management 2009;55(4):64–76

ARTICLE TYPE: Integrative Review Article

DESCRIPTION/RESULTS:

  • Author states that 4 million patients in the United Sates are affected by some type of chronic wound, and provides a review of wounds caused by skin cancers, including basal cell, squamous cell, and Marjolin's ulcer.
  • Provides review of literature related to skin cancers that can and often do mimic either an acute or chronic wound.
  • Emphasizes need for/value of a punch biopsy when there is suspicion of cancer or in situations where wounds fail to heal despite correct treatment (such as a “venous” wound that has been treated with adequate compression, but still continues to deteriorate).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article discusses the various types of skin cancer and specifically those that mimic wounds. The findings from this review remind certified nurses to strongly consider a punch biopsy to rule out malignancy when a wound fails to respond to appropriate therapy.

Legal/Regulatory Issues

W67 TITLE: Reducing the Risks of Wound Consultation: Adding Digital Images to Verbal Reports

AUTHORS: Buckley K, Adelson L, Agazio J

SOURCE:Journal of Wound, Ostomy and Continence Nursing 2009;36(2):163–169

ARTICLE TYPE: Research Report: Descriptive Comparative Study

DESCRIPTION/RESULTS:

  • The authors examined the impact of digital images on the assessment and recommendations of a WOC nurse providing remote nurse-to-nurse consultations on home care patients with wounds. Specifically, they sought to determine whether the addition of a digital photograph influenced the WOC nurse's assessment and recommendations.
  • Data were collected by home care nurses from a sample of 43 adult patients with a total of 89 wounds of various etiologies.
  • The WOC nurse first completed a wound assessment and recommendation based on a verbal report from the home care nurse. The WOC nurse then accessed digital images of the wounds and made any indicated modifications to the original assessment and management plan, providing a rationale for any changes.
  • There was a high percentage of agreement between the wound assessments completed by the home care nurse and those completed by the WOC nurse; however, areas of disagreement often impacted the overall assessment. The agreement rates between the WOC nurse's assessment and recommendations based only on a verbal report versus those based on a combination of verbal report and digital photographs were as follows: total agreement (29.2%), trivial disagreement (12.4%), and clinically relevant disagreement (58.4%).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This study suggests that WOC nurses who provide remote nurse-to-nurse consultations without directly visualizing the patients' wounds through digital images are at risk for under- or over-treating patients' wounds. In addition to improving accuracy of wound assessment, digital images provide an opportunity for the WOC nurse to mentor home care nurses in wound assessment and care.

W68 TITLE: Wound Emergencies: The Importance of Assessment, Documentation, and Early Treatment Using a Wound Electronic Medical Record

AUTHORS: Golinka MS, Clark S, Rennert R, Flattau A, Boulton AJM, Brem H

SOURCE:Ostomy Wound Management 2009;55(5):54–61

ARTICLE TYPE: Case Series

DESCRIPTION/RESULTS:

  • Authors report on case studies involving emergent wound care and the role/impact of electronic medical records (EMR) in these situations.
  • They state use of EMR reduced the number of ER visits and attributed this to the effects of ready availability of all available data (including lab reports and culture results) on the accuracy of assessment and appropriateness of management decisions.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides support for current initiatives involving transition to electronic medical records. It also highlights the impact of thorough documentation and ready availability of lab results on clinicians' ability to provide accurate assessment and timely management of chronic wounds.

W69 TITLE: 2009 Coding and Payment Changes for Hospital-Owned Outpatient Wound Care Departments

AUTHOR: Schaum K

SOURCE:Advances in Skin and Wound Care 2009;22(3): 110-112

ARTICLE TYPE: Regulatory Update

DESCRIPTION/RESULTS:

  • The author describes updated payment rates for outpatient wound care departments (Addendum A and B of OPPS Pricer: http://http://www.cms.hhs.gov/Hospital OutpatientPPS/AU/list.asp#TopOfPage.)
  • Major changes are also reviewed including increase in reimbursement for excisional selective debridement; reduction in payment for nonselective debridement; increase in payment for hyperbaric oxygen therapy and Unna Boot; reduction in payment for negative pressure wound therapy; increase in payments for evaluation and management services; and increased reimbursement for skin substitutes.
  • The author reviews current payment guidelines for low frequency noncontact nonthermal ultrasound and current guidelines for billing of medical-surgical supplies.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides valuable information for clinicians practicing in a hospital-based outpatient wound center.

W70 TITLE: Does Your Hospital-Owned Outpatient Wound Care Department Have the Required “Direct Supervision”?

AUTHOR: Schaum K

SOURCE:Advances in Skin and Wound Care 2009;22(6): 252-254

ARTICLE TYPE: Regulatory Update

DESCRIPTION/RESULTS:

  • The author describes Medicare mandated requirements for hospital-owned outpatient wound care centers, including clarification of regulations regarding onsite presence of medical director (must be on the premises and available to provide assistance and direction; does not have to be in the room).

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides guidance to clinicians in wound care departments in maintaining adherence to payment guidelines.

W71 TITLE: Defining Skin Substitutes Used as a Graft Versus Skin Substitutes Not Used as a Graft

AUTHOR: Schaum K

SOURCE:Advances in Skin and Wound Care 2009;22(7): 298-303

ARTICLE TYPE: Regulatory Update

DESCRIPTION/RESULTS:

  • Codes used to bill for skin substitutes are described.
  • Provides documentation required for any procedure coded as “graft”: preprocedural care (assessment, wound bed preparation, preparation of skin substitute); debridement and hemostasis (if indicated); application of the product to include meshing or fenestration; careful application to assure close adherence to wound surface, and fixation; and postprocedure care to include selection and application secondary dressings and arrangements/instruction for follow-up.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides valuable information for anyone working in an outpatient wound clinic.

Emerging Research/Therapies

W72 TITLE: The Toronto Symptom Assessment System for Wounds: A New Clinical and Research Tool

AUTHORS: Maida V, Ennis M, Kuziemsky C

SOURCE:Advances in Skin and Wound Care 2009;22(10): 468–474

ARTICLE TYPE: Validation of Instrument

DESCRIPTION/RESULTS:

  • Validation procedures for the Toronto Symptom Assessment for Wounds instruments are described. Five hundred thirty-one patients with variety of wounds were asked to report their top-3 wound-related symptoms (from a list of possible symptoms including pain, exudate, odor, itching, bleeding, aesthetic issues, edema, and “mass effect”), both at baseline and at each subsequent assessment. These data were used to construct the TSAS-W tool, which includes 10 symptoms (pain was changed to “baseline pain” and “pain with debridement or dressing change,” and “mass effect” was changed to “mass effect due to dressings” and “mass effect due to wound”).
  • Tool was subsequently piloted with 83 patients with 103 wounds; a general wound symptom distress score.
  • The highest distress scores were associated with malignant wounds, wounds involving the perineum and genitalia, and those creating aesthetic or cosmetic concerns.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • Further validation of this tool is needed, but the instrument has the potential to provide an objective measurement of wound-related distress and the treatment impact.

W73 TITLE: Promote Pressure Ulcer Healing in Individuals With Spinal Cord Injury Using an Individualized Cyclic Pressure-Relief Protocol

AUTHORS: Makhsous M, Lin F, Knaus E, et al.

SOURCE:Advances in Skin and Wound Care 2009;22(11): 514–521

ARTICLE TYPE: Randomized Controlled Trial

DESCRIPTION/RESULTS:

  • The researchers evaluated the impact of a wheelchair seating system designed to provide cyclic pressure relief on healing of Stage II and Stage III pressure ulcers in spinal cord injured patients.
  • Forty-two subjects were randomly allocated to usual wound care (advanced wound dressings, antimicrobial dressings, and negative pressure wound therapy) with or without the individualized pressure-relief protocol. All subjects spent at least 4 hours per day in the wheelchair and treatment persisted for 30 days.
  • Wound progress as measured by PUSH scores were significantly greater for treatment group than control group. Sixteen of 22 subjects randomized to the treatment group achieved 30% closure in 30 days, as compared to 8 out of 22 subjects in the control group.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • The findings of this study provide evidence that use of the individualized cyclic pressure-relief protocol may enhance wound healing in spinal cord injured patients with Stage II and III pressure ulcers.

Professional Practice

W74 TITLE: Building Your Personal Leadership Brand

AUTHOR: Shirley M

SOURCE:Clinical Nurse Specialist 2009;24(1):11–13

ARTICLE TYPE: Informational/Editorial

DESCRIPTION/RESULTS:

  • Authors discuss current trends in healthcare and the impact on specialty nurses such as CWOCNs. The discussion includes the impact of downsizing and the increased focus on healthcare as a business.
  • The authors advocate using an adaptive approach and the critical importance of marketing strategies tailored to the world in which we live and work.
  • The authors describe a “personal branding” approach to marketing oneself and provide specific strategies for promoting the WOC nurse role to administrators with a “bottom line” focus.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides helpful insights and strategies for marketing oneself in today's health care environment.

W75 TITLE: Estimating the Applicability of Wound Care Randomized Controlled Trials to General Wound Care Populations by Estimating the Percentage of Individuals Excluded From a Typical Wound Care Population in Such Trials

AUTHORS: Carter M, Fife C, Walker D, Thomson B

SOURCE:Advances in Skin and Wound Care 2009;22(7):316–324

ARTICLE TYPE: Review Article and Commentary

DESCRIPTION/RESULTS:

  • Authors point out that some exclusion criteria commonly used in trials evaluating technologies used to treat chronic wounds result in study populations that are not representative of the chronic wound population seen in clinical practice.
  • They argue that studies tend to enroll patients based on etiology of ulcer (venous, pressure, etc.), even though the cellular level pathology is virtually the same for all nonhealing wounds.
  • They conclude with an assertion that carefully constructed comparative observational designs can provide reliable data.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This informational article challenges our current reliance on randomized controlled trials and the “best” approach to evaluations of comparative effectiveness in chronic wound care research.

W76 TITLE: Methodological Issues in Studies of the Effectiveness of Pressure Ulcer Prevention Interventions

AUTHORS: Baumgarten M, Shardell M, Rich S

SOURCE:Advances in Skin and Wound Care 2009;22(4): 180-188

ARTICLE TYPE: Review Article and Commentary

DESCRIPTION/RESULTS:

  • The authors provide a brief review of study designs commonly used in wound-related research. They discuss the advantages and limitations of randomized clinical trials as well as alternative study designs such as nonrandomized comparison groups. The impact of sample size and blinding procedures are discussed.

WHAT DOES THIS MEAN FOR ME AND MY PRACTICE?

  • This article provides a concise and simple overview of relevant factors researchers and clinicians must consider when reviewing and interpreting findings of research evaluating the comparative effectiveness of wound care technologies.
Copyright © 2010 by the Wound, Ostomy and Continence Nurses Society