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Scientific and Clinical Abstracts From the 2016 WOCN® Society & CAET Joint Conference

Montreal, Quebec, Canada June 4-8, 2016

Journal of Wound, Ostomy and Continence Nursing: May/June 2016 - Volume 43 - Issue - p S1-S95
doi: 10.1097/WON.0000000000000226
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(GS3) Expanding Boundaries: Research AbstractsSunday, June 5, 2016—1:10 PM–2:40 PMResearch Abstract Ostomy—Evidence-Based Interventions



Colleen Drolshagen, RN, CNS, CWOCN, , Wound, Ostomy, Continence Care, Winfield, IL, Rosemary Hill, RN, BSN, CWOCN, CETN (C), , Ambulatory Program, North Vancouver, BC, Canada, and Kitty Peeten, MANP, OCN, , Nursing, Geldrop

PROBLEM: There is a shortage of rigorous evidence about the use of convexity; few studies have been conducted and existing reports are primarily reviews and case studies.1 Thus, the level of evidence available for convexity is low. PURPOSE: To establish consensus from a cross section of international stoma care experts about assessment and use of convexity for ostomy care in adults. These statements would provide a level of evidence-based information not available prior to the time of the consensus congress. METHODS: Using structured processes as outlined by Murphy et al,2 expert stoma care nurses from 9 countries convened to participate in a consensus development congress led by an expert facilitator. Panelists prepared for the congress by reviewing a comprehensive literature summary about convexity and researching their own country's literature for additional references. At the congress, panelists used electronic pads to vote sequentially on structured statements, discussing key points of disagreement where needed, and editing the statements when possible to come to agreement. Panelists also had opportunity to create new statements and present them to the panelists for their opinion/voting. Statements accepted were those on which 80% or more of the panelists agreed within 3 or fewer “rounds” of discussion, revision, and voting. RESULTS: The panelists reached agreement on 26 definitive statements about convexity. In this presentation we will share their statements about indications for use of convexity, considerations for assessment and reassessment, and when soft or firm convexity may be most appropriate. CONCLUSION: Using a structured, guided method of consensus development, global stoma care nurses provided clarity about expert opinion on use of convexity. These key statements provide evidence for use in practice, policy, and education.

1. Hoeflok J, Kittscha J, Purnell P. Use of convexity in pouching: a comprehensive review. J Wound Ostomy Continence Nurs. 2013;40(5):506–512.

2. Murphy MK, Black NA, Lamping DL, McKee CM, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3).

Ostomy—Stomal/Peristomal Complications



Toni McTigue, MSN, APNC, CWOCN, , Janet Doyle-Munoz, MSN, RN, CWON, , and Laura Doyle, BSN, RN, CWOCN, , Wound Care, Morristown, NJ; Mildred Ortu Kowalski, PhD, RN, NE-BC, , Nursing Education, Morristown, NJ; Josef Shehebar, MD, , Jason Lei, MD, , and Susan Prestera, ACNP, , Department of Surgery, Morristown, NJ

PURPOSE: Clinical observation of skin insult related to postoperative loop ostomies with and without stoma bridges were observed, and led to a quality research initiative to improve patient care. The purpose of this study was to explore variables related to peristomal breakdown, including but not limited to, the use of plastic bridges or flexible catheters to secure a loop ostomy. METHODOLOGY: An IRB-approved retrospective chart review was conducted on a nonrandom subset of hospitalized adult patients having had a surgical loop ileostomy (n = 72) or loop colostomy (n = 21) procedure, conducted between 2008 and 2015. Demographic and clinical variables for 93 adults were recorded and analyzed. STATISTICS: Descriptive and correlational statistical analyses were performed. The variables were: age, gender, length of stay (LOS), diagnosis, type of bridge, wound presence, skin integrity, and pouch leakage due to the bridge or catheter presence. RESULTS: The study population had slightly more females (57%) than males (43%) and the ages of the patients range from 19 to 96 years, with a mean 59.6 ± 16.47 (SD); median of 60 years. The average LOS for the initial surgery was 4.03 days. In this sample the primary reasons for surgical bowel diversion were cancer (60%), inflammatory disease (16%), noncancerous bowel obstruction (10%), and other (14%). Flexible catheters were used most often (53.76%), followed by plastic bridges (40.86%). Twenty-one patients (24.44%) had pouch leakage. Leakage occurred 3.55 times more often with plastic bridges compared with flexible catheters (p = 0.002). The 23% (n = 21) of patients that presented with leakage also developed erythema and rash. 11.8% (n = 11) progressed to a fungal skin infection necessitating treatment with antifungal powder. CONCLUSION: The use of plastic stoma bridges in loop ostomy patients increased peristomal leakage, inflammation, and fungal infection rates. Findings provide a springboard for interprofessional collaboration between ostomy nurses and surgeons to improve patient outcomes.

Han E, Jeong S, Oh H, et al. Is the use of a support bridge beneficial for preventing stomal retraction after loop Ileostomy? A prospective nonrandomized study. J Wound Ostomy Continence Nurs. 2015;42(4):368–373.

Buczyñski J, Darnikowska J, Dziki A, et al. Evaluation of the early results of a loop stoma with a plastic rod in comparison to a loop stoma made with a skin bridge. Pol J Surg. 2015;87(1):31–34.

Wound—Preventative Practices New



Caroline Borzdynski, BN (Hons), , Nursing, Melbourne; Dr. William McGuiness, PhD, MN, BEd Dip. T, , and Charne Miller, BA (Hons), GDip (Stat), , Nursing and Midwifery, Melbourne

Objective biophysical measures that assess skin hydration, melanin, erythema, and lipids have not been traditionally used in pressure injury (PI) risk; however, these may prove useful as part of risk assessment. The relationship between subjective visual assessment of skin condition, biophysical measures, and PI risk warrants investigation. This study used a descriptive correlational design to examine the relationship between measures of skin hydration, color (melanin and erythema), and lipids at PI-prone areas among geriatric persons (n = 38), obtained using biophysical skin measures and visual skin assessment. Twice-daily measures of hydration, color, and lipids were assessed using a diagnostic skin device over pressure-prone areas of participants over 7 consecutive days. Concurrent visual assessment of hydration and color was performed. Results obtained using the diagnostic skin device were compared with results gathered from visual assessment and examined for their association with participants' PI risk based on Norton Risk Assessment Scale scores. While epidermal hydration and skin color readings did not vary significantly over the data collection period, lipid readings could not be registered on any occasion. With the exception of skin dryness, skin parameters obtained via both objective and subjective means had significant, positive correlations. Statistically significant correlations emerged between visual assessment of skin wetness at the sacrum (r = −0.441, P < 0.01) and ischia (r = −0.468, P < 0.01) and Norton Risk Assessment Scale scores. It was found that the objective assessment of hydration (skin wetness) was also significantly associated with PI risk at the sacrum (r = −0.528, P < 0.01), as well as the right ischia (r = −0.410, P < 0.05) and left ischia (r = −0.407, P < 0.05). Erythema, when assessed objectively, was significantly correlated with PI risk at the sacrum (r = −0.322, P < 0.05). Such findings indicate that the finer measures afforded by the diagnostic skin device in the assessment of the subtle red hues displayed in erythematous skin may provide an additional advantage over traditional, clinician assessment.

Continence—Psychosocial and Quality of Life Issues



Michelle Lobchuk, RN, PhD, , Winnipeg, MB, and Fran Rosenberg, RN, BN, CNC(c), CRN(c), , Continence Care Clinic (former), Winnipeg, MB

PURPOSE: To conduct a qualitative study of affected individual and family caregiver perceptions of bladder control quality of life. BACKGROUND: Evidence suggests that avoidant behavior, judgmental attitudes, and negative beliefs held by affected individuals, their caregivers, family members, and health care providers toward urinary incontinence have deleterious consequences: e.g., discordant understanding of urinary incontinence quality of life that can lead to mismanagement, social isolation, diminished quality of life, depression, and safety hazards. There is a need to fully understand barriers and facilitators of empathic care to help nurses enhance sensitive care, boost confidence in the caregiving role, and improve quality of life of those affected by urinary incontinence. METHOD/DESIGN: Twenty-six interviews were conducted with 13 pairs of affected individuals and caregivers. Interviews were transcribed, coded, and analyzed using content analysis and constant comparison techniques. RESULTS: Five major qualitative themes were found: Life changes, Psychological Responses and Coping, Painful Responses of Others, Reticence to Seek Medical Attention, and Advice to Health Care Providers. CONCLUSIONS: Continence care is a ‘team effort’ between affected individuals and family caregivers and requires their constant vigilance. Fatalistic attitudes by professional care providers persist about effective bladder control. Affected individuals remain reluctant to broach bladder control with primary care practitioners. IMPLICATIONS FOR NURSING: Nurses need to take an empathic, patient- and family-centered approach in talking about bladder control that remains a sensitive topic for affected individuals. Both affected individuals and caregivers need, from nurses, validation of their creativity and resiliency in refusing to let urinary incontinence negate enjoyment of important aspects of their lives.

Lobchuk M, Rosenberg F. A comparison of affected individual and support person responses on the impact of urinary incontinence quality of life. Urol Nurs. 2014;34(6):291–302.

Lobchuk M, Rosenberg R. A qualitative analysis of affected individual and family caregiver responses to the impact of urinary incontinence on quality of life. J Wound Ostomy Continence Nurs. 2014;41(6):586–596. doi: 10.1097/WON.000000000000064

Continence—Evidence-Based Treatment and Management



Charlie Lachenbruch, PhD, , R&D, Batesville, IN; David Ribble, JD, , and Kirsten Emmons, MSN, RN, NEA-BC, , Global Early Innovation, Batesville, IN; Catherine VanGilder, MBA, BS, MT, CCRA, , Clinical Research, Chicago, IL

INTRODUCTION: Incontinence is recognized as a factor in the development of pressure ulcers. Limited evidence exists to demonstrate the relative increased pressure ulcer risk, the types of pressure ulcers related to incontinence, and sufficiency of risk assessment tools relative to incontinence. METHODS: This study analyzed the 2013 and 2014 International Pressure Ulcer PrevalenceTM Surveys (IPUP) comparing (1) prevalence and relative risk of developing facility acquired pressure ulcers (FAPU), and (2) severity of FAPUs by risk assessment level in incontinent vs. continent patients. The IPUP survey is an annual voluntary survey of hospitalized patients or residents in facilities conducted over a predetermined 24-hour period on a predetermined day. Demographics, presence of pressure ulcers, pressure ulcer risk scores, and other pertinent data are collected. This study analyzes aggregate data by incontinence category for the prevalence and severity of FAPUs. RESULTS: IPUP records (n = 176,689) were analyzed with 83,800 continent patients compared to 92,889 patients (53%) who either were managed by Foley or fecal management systems or had unmanaged incontinence (all considered incontinent in this analysis). Overall prevalence of pressure ulcers was 4.1% for continent patients and 16.3% for incontinent. FAPU prevalence was 1.6% as compared to 6.0%, respectively. The relative risk for PU development in incontinent patients was much higher than predicted by Braden risk score. As wound severity increased, the odds ratios for pressure ulcer development for incontinent patients increased dramatically. DISCUSSION: Incontinent patients were older, had higher Braden Risk scores, higher overall, and FAPU prevalence. Incontinence was associated with increased risk of all pressure ulcers, but especially severe pressure ulcers. Incontinent patients assessed at low PU risk demonstrated higher than expected FAPU prevalence. CLINICAL RELEVANCE: These results reinforce the importance of incontinence as a pressure ulcer risk factor for serious pressure ulcers independent of Braden score.

(W408) Wound Abstract PresentationsTuesday, June 7, 2016—3:10 PM–4:10 PMWound—Preventative Practices New



Nancy Beinlich, MSN, RN, CWON, , Nursing Professional Practice, Development, and Research Department, Akron, OH, and Anita Meehan, MSN, RN-BC, ONC, FNGNA, , Nursing, Akron, OH

This presentation examines the process of creating and validating a perioperative pressure ulcer risk assessment and prevention tool. A root-cause analysis of hospital-acquired pressure ulcers (HAPUs) at a Midwest level one trauma center revealed 69% of patients who developed HAPUs had surgery during their stay. Staff in the perioperative area indicated that pressure ulcer risk assessment was not routinely performed on patients undergoing surgery. A review of the literature and an IRB-approved chart audit of surgical patients revealed risk factors in those who developed HAPUs: age 70 years or older, diabetes, Braden Scale score of 16 or less, prolonged surgical time (≥50), multiple surgeries during the same admission, and preexisting pressure ulcer. These factors were incorporated into a perioperative risk assessment tool. Patients with one risk factor were considered at risk for tissue breakdown. A total of 699 surgical inpatients were enrolled in the study. The control group of 350 patients was randomly selected prior to the implementation of the protocol. The treatment group of 349 surgical patients was screened for pressure ulcer risk using the protocol. There were statistically significant differences between the control and treatment groups. Treatment group subjects were older (t(590) = 7.338, p ≤ .001), more likely to have diabetes (χ2(1) = 16.51, p ≤ 0.001) and had longer surgical times (t(694) = −10.134, p ≤ .001). Control group subjects had prior surgery (χ2(1) = 47.217, p ≤ .001) and lower Braden Scale scores (t(570) = −4.179, p < .001). There were statistically significantly fewer pressure ulcers in the treatment group (1.7%, 6/349) versus the control group (4.3%, 15/350) (χ2(1) = 3.950, p = .047). It is estimated that 5% of patients admitted to the acute care setting develop HAPUs with rates increasing to 45% if the patient undergoes surgery.1 Utilization of this tool can aid in implementation of prevention measures prior to, during, and after surgery, thereby reducing the incidence of HAPUs in surgical patients.

1. Lupear S, Overstreet M, Krau S. Perioperative nurses' knowledge of indicators for pressure ulcer development in the surgical patient population. Nurs Clin North Am. 2015;50:411–435.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Bonnie Johnston, BA, BSN, RN, CWOCN, MSN-c, , Matthew Mutch, MD, , and Matthew Silviera, MD, , Department of Surgery—Section of Colon and Rectal Surgery, St. Louis, MO

IMPORTANCE: Colorectal surgery infection rates range from 15% to 30% (Keenan, 2014). Preventive bundles are being implemented to reduce surgical site infection (SSI) rates. Colorectal SSI bundles can reduce infection rates by up to 33.3% with an associated cost savings to the healthcare system of up to $170 million per year (Wick, 2012). OBJECTIVE: To evaluate the impact of WOC nurse (wound ostomy continence nurse/WOC nurse) developed patient education program as a component of colorectal surgery SSI prevention care bundle (SSI-PCB). SETTING AND PARTICIPANTS: Between January 1, 2014, and June 30, 2015, 307 patients underwent colorectal surgery at an academic tertiary referral center and were included in both the SSI-PCB database and the National Surgical Quality Improvement Program (NSQIP). DESIGN: WOC nurse education included: (1) patient focused instruction booklet developed for SSI-PCB by the WOC nurse; (2) face-to-face visit with the WOC nurse to discuss SSI-PCB components: mechanical bowel prep, chlorhexidine gluconate 4% solution bathing, and antibiotic prophylaxis. This is a retrospective study of prospectively collected SSI-PCB compliance data and NSQIP outcome data. The performance of the WOC nurse education was analyzed to determine its relationship to the rate of postoperative SSI as captured by NSQIP. RESULTS: The WOC nurse education occurred in 239 of the 307 patients (77.9%). Compliance was statistically higher in patients for key preoperative bundle components: 89.7% (208/232) vs 62.7% (42/67) for mechanical bowel prep (p < 0.001); 93.2% (218/234) vs 67.7% (44/65) for the CHG bathing (p < 0.001); and 86.4%(203/235) vs 50.8% (34/67) for the antibiotic prophylaxis (p < 0.001). Those who did not receive education had an SSI rate of 10.3% (7/68) compared to 5.0% (12/239) who did receive education (p < 0.001). CONCLUSION: The impact of a WOC nurse–developed patient education role in SSI prevention is overlooked. Our study validates the WOC nurse role in developing and distributing patient education materials. Patient education prior to surgery leads to increased adherence to the SSI-PCB patient components and has a positive impact on SSI outcomes.

Keenan JE, Speicher PJ, Thacker JKM, Walter M, Kuchibhatla M, Mantyh CR. The preventive surgical site infection bundle in colorectal surgery. JAMA Surg. 2014;149(10):1045–1052.

Wick EC, Hobson DB, Bennett J, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215(2):193–200.

Wound—Management of Complex Wounds



Christine Murphy, RE CETN(C), PhD, , Pamela Houghton, PT, PhD, , Dianne Bryant, PhD, , and Gregory Rose, MD MSc, FRCPC, , Health and Rehab Sciences, London, ON; Tim Brandys, MD, Med, FRCSC, FACS, , Vascular Surgery, Ottawa, ON, Canada

PURPOSE: To determine whether 22.5 kHz low-frequency contact ultrasound debridement (LFCUD) applied in a nurse-led vascular wound clinic improves lower extremity wound healing in people with peripheral vascular disease (PVD). DESIGN: Randomized controlled clinical trial; single blinded. METHODS: Consecutively sampled adults (n = 68) with below knee, full-thickness wounds > 1 cm2 and followed by the Vascular Surgery service were stratified based on negative pressure wound therapy and randomly assigned to standard wound care (SWC) which included conservative sharp debridement, or LFCUD plus SWC. Healing was determined incorporating baseline data as covariates, to calculate percentage reduction in wound surface area (% WSA) and change in wound appearance (revised Photographic Wound Assessment Tool: revPWAT) after 4 weekly treatments of SWC, or LFCUD + SWC. RESULTS: The mean %WSA reduction posttreatments (Week 5) was greater (31.63%) in the LFCUD group than in the SWC group (18.06%), but this finding was not statistically significant (p = 0.485). Wound appearance was significantly improved (p ≤ 0.01) in the LFCUD group which declined by 7.34 revPWAT points (5.8-8.9, 95% CI) compared to SWC group of 2.98 revPWAT points (1.4-4.6, 95% CI). By Week 5 only LFCUD patients had closed wounds (n = 2) or were ready for skin grafting (n = 2). CONCLUSION: LFCUD improves wound appearance in patients with PVD, supports closure and is suitable for nurse application.

Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: A vital component of wound bed preparation. Adv Skin Wound Care. 2006;19(9):506–517.

Young SR, Dyson M. The effect of therapeutic ultrasound on angiogenesis. Ultrasound Med Biol. 1990;16(3):261–269.

Tan J, Abisi S, Smith A, Burnand KG. A painless method of ultrasonically assisted debridement of chronic leg ulcers: A pilot study. Eur J Vasc Endovasc Surg. 2007;33(2):234–238.

Herberger K, Franzke N, Blome C, Kirsten N, Augustin M. Efficacy, tolerability and patient benefit of ultrasound-assisted wound treatment versus surgical debridement: a randomized clinical study. Dermatology. 2011;222(3):244–249.

(C406) Continence Abstract PresentationsTuesday, June 7, 2016—11:00 AM–12:00 PMContinence—Issues in Bladder and Bowel Continence Management



Manuela Mandl, MSc, , and Christa Lohrmann, PhD, RN, , Institute of Nursing Science, Graz; Ruud Halfens, PhD, , Department of Health Services Research, Maastricht, the Netherlands

BACKGROUND: Incontinence in older people is a major nursing care problem that entails a high workload for nurses and a large burden for affected individuals. Internationally and in Austria, the availability of reliable and valid long-term nursing care data for incontinence in the nursing home setting is limited. METHODS: The Austrian repeated cross-sectional study entitled the “Prevalence Measurement of Care Problems” contains data from more than 6000 nursing home residents (2009-2013). Out of these data, nursing home residents were identified who had participated over a period of 4 years (2009-2012 and 2010-2013). Repeated measurement tests were used for metric data, and nonparametric tests and cross tables were used for categorical variables. RESULTS: Most of the 108 residents were female (85.2%) and the prevalence of urinary incontinence increased statistically by more than 10% from the first to the last measurement point. Additionally, the increase of nursing care dependency was statistically significant. The use of nursing interventions saw a statistically significant increase over the time period regarding, e.g., adaption of the environment (+36%), adaptation of clothes (+61%), and mattresses (+38%). We could not find statistically significant results, although there were increases in both frequency and volume of urinary incontinence. CONCLUSIONS: The prevalence of urinary incontinence as well as residents' care dependency, both factors known to influence quality of life, increased over time. In order to understand the progression of urinary incontinence in more detail (frequency, volume, etc.), further research is needed—especially longitudinal studies—focusing on consequences for the affected individuals.

Continence—Psychosocial and Quality of Life Issues



Lori Saiki, PhD, RN, , Nursing, Denver, CO, and Robin Meize-Grochowski, PhD, RN, , Nursing, Albuquerque, NM

PURPOSE: To explore the relative contributions of female urinary incontinence symptom severity and psychosocial factors to relationship satisfaction for midlife women and their intimate partners. BACKGROUND: The Corbin and Strauss Theory of Collaborative Chronic Illness Trajectory Model (Corbin & Strauss, 1984, 1988), current evidence regarding the psychosocial impact of living with urinary incontinence, and the impact of chronic illness on intimate relationships informed the choice of study factors. PARTICIPANTS: Partnered women aged 45-65 with self-reported stress, urgency or mixed urinary incontinence were purposively recruited via clinic, community, social media, and snowball sampling. Recruited women offered participation to their partner. METHODS: A descriptive, point-in-time analysis of women and partner responses (N = 43 dyads) to anonymous, mailed surveys comprised of established instruments chosen as measures of: urinary incontinence symptom severity, relationship satisfaction, quality of interpersonal interactions (relational ethics, sexual quality of life, incontinence-related communication), and women's self-concept (self-esteem, body image, depression, anxiety). RESULTS: Women and partner scores on relationship variables were congruent by paired-samples t test (p < .05). Incontinence symptom severity demonstrated no significant correlations with the other study variables. Correlation matrix demonstrated moderate to large correlations among measures of women's self-concept and measures of the relationship (r = −0.39 to −0.71, p < .05), including relationship satisfaction (r = 0.31 to 0.87, p < .05). On exploratory standard multiple regression, study measures explained 43.8% of the variance in partners' relationship satisfaction scores (F(6, 33) = 4.286, p = .003; R2 = 0.438, adjusted R2 = 0.336), with significant unique contributions from sexual quality of life (14%) and women's depressive symptoms (10%). CONCLUSIONS: When working with women who have chronic urinary incontinence, an assessment of sexual quality of life and depressive symptoms may be helpful in assessing the impact of symptoms on the woman's intimate relationship.

Corbin JM, Strauss AL. Collaboration: couples working together to manage chronic illness. Image J Nurs Scholarsh. 1984;16(4):109–115.

Corbin JM, Strauss AL. Unending Work and Care: Managing Chronic Illness at Home. San Francisco, CA: Jossey-Bass Publishers; 1988.

Wound—Evidence-Based Interventions



Mary R. Brennan, RN, MBA, CWON, , North Shore University Hospital, Manhasset, NY, Catherine Milne, APRN, MSN, BC-ANP/CNS, CWOCN-AP, , Bristol, CT, and Bruce Ekholm, MS, , Critical & Chronic Care Solutions Division, St. Paul, MN

PURPOSE: Verify the efficacy of an investigational barrier film product at managing severe skin breakdown associated with incontinence in an open-label, nonrandomized, prospective study including 16 patients. SUBJECTS AND SETTING: Patients over 18 years old, being cared for in a facility providing nursing care 24 hours/day, with moderate to severe incontinence-associated dermatitis, with or without continued fecal or fecal and urinary incontinence. Twelve of the patients had epidermal skin loss and four had severe redness. METHODS: The investigational product is a formulation based on acrylate chemistry. The barrier film application schedule was twice a week for up to 3 weeks for a maximum of 6 applications during the study period. A skin assessment tool designed for IAD was used to document each patient's IAD score over time. The efficacy of the investigational product was evaluated in terms of IAD score improvement over the study period. In addition, complete reepithelialization was recorded when observed, and pain scores were noted in patients able to report pain. RESULTS: The IAD score improved in 13 of 16 patients, remained unchanged in 1, and deteriorated in 2 (1 noncompliant and 1 died). The median percent improvement in IAD score was 96%, which was significantly different from zero (p = 0.013 by Wilcoxon signed rank test). Four of the patients with epidermal skin loss had complete reepithelialization with 4-6 applications of the barrier film, and 5 had substantial improvement. The 4 patients with severe red skin returned to normal skin with 2-4 barrier film applications. Substantial pain reduction was reported by all 9 patients who reported pain at enrollment. There were no reported adverse events associated with the barrier film. CONCLUSIONS: The formulation successfully created a protective barrier in the presence of oozing exudate and blood. The new product was effective as a protective barrier film in presence of incontinence.

Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;39:61–74.

Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39:303–315.

Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T: Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs. 2009;65:1141–1154.

(O309) Ostomy Abstract PresentationsMonday, June 6, 2016—2:40 PM–3:40 PMOstomy—Psychosocial and Quality of Life Aspects



Debbie Miller, MN, RN, CETN(C), , Oncology, Toronto, ON, Canada, Molly McCarthy, MA, , Clinical Psychology, Toronto, ON, Canada, Karen Fergus, PhD, C. Psych, , York University, Department of Psychology and Sunnybrook Odette Cancer Centre, Toronto, ON, Canada, and Jason Isaacs, H.BA, , Toronto, ON, Canada

BACKGROUND: It is estimated that in 2015, 13.9% of men and 11.5% of women will develop colorectal cancer in Canada (Canadian Cancer Society, 2015). Individuals presenting with locally advanced, low lying, or recurrent rectal cancer may require a permanent colostomy. While there is some literature that has explored the impact of a permanent stoma on spouses, the processes which underlie couples' successful adjustment to rectal cancer and living with a permanent colostomy are not yet well understood. PURPOSE: The current study aims to better understand the adjustment of couples to life with a permanent colostomy following an abdominal perineal resection for locally advanced or recurrent rectal cancer. Specifically, what types of challenges do these patients and their partners face and how do they attempt to overcome them? METHODOLOGY: Eleven patients and their partners (10 heterosexual, 1 same-sex couple) were interviewed about their adjustment experience. Each dyad's interview was transcribed verbatim and the text was analyzed using the grounded theory method (Glaser & Strauss, 1967; Graneheim & Lundman, 2004). RESULTS: Several themes emerged through the analysis of data including “Acute Embarrassment,” “Controlling What's Controllable,” “Marred Body Image and Sexuality,” and “It's a Foreign Land.” Given the depth and breadth of the information collected, the focus of this presentation will address body image and sexuality, an area not often addressed by clinicians. CONCLUSIONS: These results are important in elucidating common practical and psychosocial challenges faced by couples adjusting to a permanent colostomy after treatment for rectal cancer. The results provide insight into the ways couples cope with these concerns and also reveal areas where couples have a lack of support, wherein clinicians may help to support couples' adjustment.

Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine Publishing Company; 1967.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–112.∼/media/

Ostomy—Evidence-Based Interventions



Joyce Pittman, PhD, CWOCN, , Wound Ostomy Continence, Indianapolis, IN, Susan Rawl, RN, PhD, , Indiana University School of Nursing, Indianapolis, IN, Ginger Salvadalena, PhD, RN, CWOCN, , Global Clinical Affairs, Libertyville, IL, and Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL

Short hospital stays and fragmented follow-up care make it difficult for people with new ostomies to obtain information, self-management training and support. Web-based patient ostomy support resources may provide this essential information. The purpose of this study was to evaluate the reach, acceptability, usability and satisfaction with Web-based patient support resources available for patients with an ostomy. This cross-sectional, descriptive study enrolled 202 people who had ostomy surgery within the past 24 months. Data were collected by trained telephone interviewers regarding demographics, ostomy information, use of the Internet, acceptability, usability and satisfaction with preferred ostomy Web sites. Of the 202 participants, almost 88% reported leakage and 69% reported peristomal dermatitis. Less than half of participants (45%) reported using the Internet as a source of ostomy information. Among those who did, 30% identified a preferred Web site. YouTube was the most commonly used Web site (15%) with Hollister, UOAA, and Coloplast Web sites tied for second place (11%). Twenty-three (85%) participants stated information on their preferred Web site helped them better understand their ostomy, 89% thought the Web site used language they could understand, and 70% reported the information was visually appealing. Almost all (93%) indicated the Web site kept their interest and attention, and 96% stated they would recommend the Web site to others. Among all 202 participants, other helpful sources of information and support included ostomy nurses (84%); brochures/pamphlets (74%); surgeons (70%), other health care providers (36%), family (33%), primary care providers (31%), books (27%) and friends (22%). Many indicated that their ostomy supply company had been a helpful source of information and support as they had received written materials, CDs, DVDs, and other types of valuable assistance from them. Future research is needed to develop and test best Web-based patient support methods to provide essential ostomy information, self-management training and support resources.

United Ostomy Associations of America, 2012. Accessed October 8, 2012.

Pittman J, Bakas T, Ellett M, Sloan R, Rawl S. Psychometric Evaluation of the Ostomy Complication Severity Index. J Wound Ostomy Continence Nurs, March/April 2014;41(2):147–157.

Turnbull G. The ostomy files: ostomy statistics: The $64,000 question. Ostomy Wound Manage. 2003;49(6):22–23. Accessed June 21, 2007.

Colwell J, Goldberg M, Carmel J. The state of the standard diversion. J Wound Ostomy Continence Nurs. 2001;28:6–17.

Pittman J, Rawl SM, Schmidt CM, Grant M, Ko CY, Wendel C, Krouse RS. Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy. J Wound Ostomy Continence Nurs. September/October 2008;35(5):493–503.

Ostomy—Stomal/Peristomal Complications



Ginger Salvadalena, PhD, RN, CWOCN, , and Melissa Menier, , Global Clinical Affairs, Libertyville, IL

Adjustment to an ostomy may be difficult if wearing the pouching system creates discomfort. Pruritus, especially when chronic, may be distressing and difficult to treat (Bautista, Wilson, & Hoon, 2014). Little is published in the stoma care literature about pruritus except in relationship to certain skin conditions such as candidiasis and dermatitis. We explored peristomal itch to learn how ostomy nurses and individuals with stoma compared in their experiences with this issue. AIMS: Explore peristomal itch reported by individuals with stomas. Assess stoma care nurse opinions about peristomal itch. Identify similarities and differences in the responses of the 2 groups. METHODS: Participants responded to questions posed in an electronic survey which was created by the authors and reviewed and approved by an independent review board. RESULTS: Over 57% of the 164 respondents with stomas reported experiencing itching around their stoma and 35% of them said the skin most often or always appeared healthy when itchy. The majority (74%) of these respondents did not discuss the problem with a healthcare provider. About 71% of the 259 nurse respondents have evaluated patients with pruritus and healthy appearing skin. The most common causes identified by nurses were dry skin, sensitivity to adhesives or products, and leakage. Individuals with stomas identified the most common causes as leaving the pouching system on too long, leakage, moisture, and product sensitivities. CONCLUSIONS: Peristomal pruritus is common and occurs even in the absence of visible skin redness or irritation. Ostomy nurses should include questions about pruritus as a routine part of their assessment of individuals with stomas. Further study is needed to investigate causes and treatment for this peristomal skin problem.

Bautista DM, Wilson SR, Hoon MA. Why we scratch an itch: the molecules, cells and circuits of itch. Nat Neurosci. 2014;17(2):175–182.


CASE STUDY ABSTRACTSOstomy—Product Selection and Innovations



Aimee Frisch, BSN, RN, CWOCN, , Nurse Specialist, Menomonee Falls, WI, and Bonnie Johnston, BA, BSN, RN, CWOCN, MSN-c, , Department of Surgery—Section of Colon and Rectal Surgery, St. Louis, MO

OBJECTIVE: To evaluate the benefit of using ceramide infused skin barriers on patients with and without healthy peristomal skin. SIGNIFICANCE: Literature demonstrates that as many as 70% of ostomy patients experience stoma-related complications. Skin irritation, rash, and pouch leakage are the most common complaints.1 Maintaining peristomal skin health is essential to maintaining quality of life. Ceramide, a natural component in human skin, plays a critical role in maintaining skin health.2 Until now, clinicians have been able to choose from 2 categories of skin barriers: extended wear and standard wear. Barrier selection is based on absorption and adhesion.3 A ceramide-infused barrier is new technology that has provided WOC/ET nurses with an additional barrier option to help maintain healthy peristomal skin. METHOD: Ceramide skin barriers were used on 7 patients; a combination of ileostomy and colostomy patients (6/7 followed for 7-14 days; 1/7 followed >30 days). All patients had a DET score between 2 and 7 at baseline. The DET tool scored patient's skin integrity before and after use of the barrier. Case studies and photos documented patient demographics, outcomes, and assessments. Accessories such as paste and barrier rings were used when required to improve barrier fit. RESULTS: 7/7(100%) DET < 2 at 7 days. 1/1(100%) DET 0 for 30 days. CONCLUSION: All patients who had peristomal skin breakdown and used the ceramide-infused skin barrier showed improvement. Patients who had healthy peristomal skin maintained healthy skin; DET < 2. The positive outcomes from the use of this product suggest a change of practice from a reactive to proactive approach in terms of maintaining healthy peristomal skin. More case studies are needed to determine the broader use of ceramide infused skin barriers and employing their use as a first choice for ostomy patients with healthy peristomal skin.

1. Richbourg L, Thorpe JM, Rapp CG. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurse. 2007;34:70–79.

2. Choi MJ, Maibach HI. Role of ceramides in barrier function of healthy and diseased skin. Am J Clin Dermatol. 2005;6(4):215–223.

3. Colwell J, Carmel J, Goldberg M. Selection of pouching system. WOCN Core Curriculum Ostomy Management. Philadelphia, PA: Wolters Kluwer; 2014: 120–130.

Wound—Preventative Practices New



Anita Shelley, MSN, RN, CNS, CWOCN, , Indianapolis, IN

Approximately 775 babies in the United States are born with an omphalocele each year. An abdominal wall defect where herniation of abdominal organs such as the small intestine, part of the large intestine, liver and spleen make up a giant omphalocele. The herniating organs are covered by a membranous sac, which can rupture during birth, increasing the risk for neonatal sepsis. Sepsis remains one of the leading causes of morbidity and mortality both among term and preterm infants. In the past year, 3 premature newborns (33 to 37 weeks) were admitted to a Mid-Western tertiary referral children's hospital with giant omphalocele. Two of the newborn omphalocele sacs were ruptured at birth requiring immediate surgery to contain organs. Tissue Matrix graft was placed around organs to stimulate neoepithelialization. The third newborn kept an intact membranous sac. All 3 newborns were treated using a fatty acid derivative in DACC (dialkylcarbamoyl chloride) technology dressing as a contact layer over the omphalocele to irreversibly bind with bacteria, without releasing endotoxins, through hydrophobicity action. Negative pressure wound therapy (NPWT) with white foam was changed 3 times per week to maintain moisture at the graft site and over membranous sac. The newborn with the intact sac grew partial neoepithelial tissue on the sac prior to surgery for closure. One newborn with a graft showed no infection with the omphalocele but had respiratory complications and passed away. The other newborn with a graft had surgery reducing the defect but required a second tissue matrix graft. DACC dressing was not used on the second graft under NPWT and a pseudomonas infection developed that required systemic antibiotics. DACC technology dressing was reinitiated again under NPWT with no further infections occurred. A complete closure was achieved.

Centers for Disease Control and Prevention: Facts about omphalocele. September 14, 2015. Retrieved November 2015 from

Kammerlander G, et al. Non-medicated dressing as an antimicrobial alternative in wound management. Die Schwester Der Pfleger 2007;46:84–87.

Ljungh A, Yanagisawa N, Wadstorm T. Using the principle of hydrophobic interaction to bind and remove wound bacteria. J Wound Care. 2006;15(4):175–180.

Shah BA, Padbury JF. Neonatal sepsis. Virulence. 2014;5(1):170–178.

Wound—Management of Complex Wounds



Anita Shelley, MSN, RN, CNS, CWOCN, , Indianapolis, IN

An extremely premature neonate, 23 weeks' gestation, was admitted to a Mid-Western tertiary referral children's hospital. Weighing just 1000 grams at 25 weeks, comorbidities included respiratory failure, polymicrobial sepsis, renal failure, and newly developed necrotizing enterocolitis (NEC) with diffuse peritonitis. Surgery was performed to create an end ileostomy, however an unstable postop course and worsening hepatic dysfunction complicated healing and nutrition. Abdominal distension continued and bowel strictures were discovered, which required another surgery at 30 weeks' gestation. During this 6-hour surgery, enterotomies were made while lysing adhesions. A mesh graft covered over an open distended abdomen and was sewn to fragile tissue. Multiple fistulas began to mature and drain bile, resulting in frequent pouch changes and deterioration of the graft. Various dressing and pouching techniques were tried by bedside nursing until pouching became extremely challenging resulting in numerous daily changes. This neonate's condition deteriorated with further complications and central line–related blood stream infections. Multiple fistula across a small abdomen with limited skin space posed a pouching challenge. Peristomal skin was abused by the intestinal effluent, bloody mucous drainage and constant adhesive removal. DACC (dialkylcarbamoyl chloride) technology was tried on the friable peristomal skin. This cellulose-coated dressing irreversibly binds with bacteria through hydrophobic action and decreases bioburden. Hydrocolloid paste was molded to fit around the stomas. An adult-size wound manager was cut to fit around the abdominal stomas. To help maintain the drainage, a red rubber catheter was used in the wound manager and connected to low intermittent suction. This pouching system and DACC dressing was changed twice per week by the CWOCN. The periwound skin began forming epithelial tissue and no further central line infections developed after implementation of the DACC dressing and wound manager. On day 233, multisystem organ failure contributed to loss of life.

Kammerlander G, et al. Non-medicated dressing as an antimicrobial alternative in wound management. Die Schwester Der Pfleger. 2007;46:84–87.

Ljungh A, Yanagisawa N, Wadstorm T. Using the principle of hydrophobic interaction to bind and remove wound bacteria. J Wound Care. (2006;15(4):175–180.

Shah BA, Padbury JF. Neonatal sepsis. Virulence. 2014;5(1):170–178.

Wound—Product Selection and Innovations



Annette Gwilliam, RN, BSN, CWS, ACHRN, , Utah Valley Wound Care and Hyperbaric Medicine, Provo, UT, and Marc Robins, DO, MPH, , Intermountain Healthcare—Utah Valley Wound Care and Hyperbaric Medicine, Provo, UT

For nearly a half century, the benefits of moist wound healing have been compared with dry techniques (1). The benefits of moisture balance are key in the healing process. We tested a new dressing designed to provide a moist wound environment through the introduction of a small volume of topical solution. The system includes a semiocclusive dressing and an innovative pocket-size delivery device. Below are 3 of the 15 patients who received 57 procedures. #1: 47-year-old diabetic male: laparoscopic repair of a ventral hernia, dehisced leaving a chronic, nonhealing open wound. Preliminary healing occurred, but had a setback (increase in size of the wound 0.14 cm2/day for 9 weeks). The wound then stalled for 19.6 weeks with a 0.01 cm2/day decrease. The system was applied using 3% gentamicin solution showing a decrease of 0.2 cm2/day, closed in 2.6 weeks. #2: 50-year-old male (diabetic, obesity, edema and peripheral neuropathy) had a nonhealing ulcer on his left medial calf. After the system was applied using 3% gentamicin solution, the wound decreased in size at a rate of 0.08 cm2/day over the next 7.2 weeks. The device was removed with wound closure 9.2 weeks later. #3: 26-year-old female (venous stasis disease and morbid obesity) had a traumatic injury to her right shin. A tunnel developed with an initial area measurement of 1.95 cm2 and depth of 1 cm. When the tunnel was packed with a silver collagen dressing and the system applied (using sterile water), the tract decreased by 0.22 cm2/day, healed in 3 weeks. CONCLUSION: This new system of instilling a small volume of solution shows great promise in improved healing rates either by maintaining a moist environment or with addition of slow release of antiseptic solution.

1. Winter G. Formation of the scab and the rate of epithelisation of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293–294.

Wound—Management of Complex Wounds



Annielyn Azor—Ocampo, BSN, RN, CWOCN, DAPWCA, , Lincoln, NE

STATEMENT OF CLINICAL PROBLEM: A 70+-year-old diabetic patient with severe aortic stenosis with ejection fraction of 55% accompanied by complicated knee replacement due to osteoarthritis of the right knee. During hospitalization, patient further developed renal insufficiency, and stroke to the right side of the body. Patient developed probable embolization of the gastrocnemius muscle to right lower extremity along calf region that revealed significant necrosis of the skin, subcutaneous tissues and muscles, fascia and tendon. DESCRIPTION OF PAST MANAGEMENT: Daily application of enzymatic debridement therapy was initiated with once a week conservative sharps debridement at bedside. Noncontact low-frequency ultrasound (NLFU) was also initiated. In spite of the combined treatment modalities, wound bed continues to be necrotic and nonresponsive to treatments. CURRENT CLINICAL APPROACH: Biosurgical therapy was initiated to assist with the different methods of debridement. Larvae that have been applied in the wound bed was sealed within a finely woven polyester net dressing and remained in the wound throughout the treatment. Larval secretions penetrated through the dressing where nonviable tissue was liquefied. Bagged larvae was left in the wound for 4 days and covered with a saline wet to moist dressing, periwound skin was protected with zinc oxide ointment. PATIENT OUTCOMES: Bagged larvae was applied for 3 consecutive times in a period of 15 days. Nonviable tissues have been effectively removed through biosurgical therapy. Wound volume has decreased from 71.4 cm2 to 28.7 cm2. CONCLUSION: Biosurgical therapy is an innovative delivery system and clinically effective in reducing bioburden. It allows clinicians to debride wounds with precision while maintaining patients comfort. The ease of application and shorter debridement times make this method a cost-efficient debridement solution for slow and nonhealing wounds.

Sherman RA. Maggot therapy takes us back to the future of wound care: New and improved Maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2), 336–344.

Davydov L. Maggot therapy in wound management in modern era and a review of published literature. J Pharm Pract. 2011;24(1):89–93.

Wound—Preventative Practices New



Barbara Nordquist, MSN, RN, CWOCN, ACNS-BC, and Cindy Davis, BA, RN, CWON, , Wound Team, Sioux Falls, SD

“Prone positioning of critically ill patients with acute respiratory distress syndrome is associated with an increased likelihood of pressure ulcer development.” Hospital-acquired pressure ulcers are a never event and significantly impact patient quality of life and facility reimbursement. In the prone patient, hospital-acquired pressure ulcer incidence rates as high as 65% have been reported. To help maximize oxygenation, the patient is positioned prone until returned to the supine position. The length of time a patient is prone varies based on their response to the procedure and the physician's order. Because of the difficulty of proning these patients and the need for multiple staff to assist, patients are frequently left prone for up to 12 hours and are at increased risk for developing multiple site pressure ulcers. Our facility developed a prone bundle and standardized the process to offload pressure, decrease friction and shear, and provide moisture management for the prone patient. The 8 patients who were cared for using the prone bundle did not develop any pressure ulcers, whereas those who were cared for without the use of the prone bundle developed 1 or more pressure ulcers on their prone surface. Use of a preassembled prone bundle makes it easy for the nurse to do the right thing and benefits the patient. “Care bundles aim to improve standard of care and patient outcome by promoting the consistent implementation of a group of effective interventions.” Because of the complexity of the variety of products needed to appropriately prevent patient injury, placing them in a kit which is readily available decreases process variation and ensures that adoption of the practice is likely to occur.

Camporota L, Brett S. Care bundles: implementing evidence or common sense? Crit Care. 2011;15(3):159. doi: 10.1186(cc10232.

Edsberg LE, Langemo D, Baharestani MM, Posthauer ME, Goldberg M. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4). http://((

Wound—Management of Complex Wounds



Bonnie Blackburn, RN, BSN, CWCN, , and Vanessa Johns, RN, BSN, CWCN, , Wound Care, Suffolk, VA

STATEMENT OF CLINICAL PROBLEM: A 64-year-old male had a left total knee arthroplasty on 3/23/15. The incision had blistering at discharge. The patient developed a necrotic soft tissue infection and was subsequently admitted to the hospital for incision and drainage. Risk for amputation was discussed with patient by orthopedics. DESCRIPTION OF PAST MANAGEMENT: Postop, the incision was dressed with hydrofiber with silver POD3. Blistering developed, changed treatment to contact layer with absorbent pads. At 6 weeks, postop incision measured: 14.1 cm × 9 cm × 2.5 cm with undermining from 2 to 9 o'clock up to 2.8 cm with tendon and bone exposure. Initial debridement on 5/13/15 with cultures showed S. aureus, enterococcus, and acinetobacter. The plan was changed to NPWT and aggressive IV antibiotic therapy. Wound measurement after debridement was 17 cm × 11 cm × 5 cm. CURRENT CLINICAL APPROACH: Patient returned to OR for further debridement and antibiotic spacer placement on 5/18/15. Cultures still positive for enterococcus and Ralstonia pickettii. After WOC nurse consult, plan changed to NPWT with antimicrobial irrigation. A broad spectrum NPWT antimicrobial solution was used. Initial settings were: 100-mL infusion with 10-min dwell every 2 hours. Pressure setting at 150 mmHg. After 2 weeks of therapy, patient was transported to tertiary care facility for flap and hardware salvage/removal. Wound measured 16.5 cm × 9 cm × 2 cm. PATIENT OUTCOMES: Limb salvage was achieved with use of NPWT with irrigation as part of multidisciplinary plan of care. Patient transferred to tertiary hospital where joint removal and flap were performed. Patient is ambulatory with brace and plans for new TKA in future. CONCLUSIONS: Use of NPWT with microbial irrigation can aid in limb salvage with necrotizing soft tissue infection when used in conjunction with antibiotic therapy and/or serial debridement.

Wound—Preventative Practices New



Camila Shimura, PhD student; CWOCN, , Ribeirão Preto, Sao Paulo, Brazil; Francisco Tiago, BSN, RN, CWOCN, , Helena Megumi Sonobe, PhD, MSN, BSN, , and Janaína da Silva, MSN, BSN, RN, , Ribeirão Preto, Sao Paulo, Brazil

The home care visit by a WOC nurse is a strategy to ensure the postoperative rehabilitation of patients with intestinal ostomy. Aimed to evaluate 3 patients in to identify the demands of nursing care needs to encourage the rehabilitation of these patients. Prospective case study of 3 patients with intestinal diseases (cancer and inflammatory disease), assessed by the WOC nurse in home care, with printed and photographic records. Result: Case 1. male patient, 78 years old, with obesity, hypertension and diabetes diagnosed 2 months ago with colorectal cancer with terminal ileostomy (changing the equipment several times a day; low adhesion to the skin); cut larger base than the stoma; absence in use of ostomy supplies; it has identified the need to adapt the equipment. Case 2. A male patient, 75 years old, underweight, diagnosed 3 months ago with colorectal cancer in adjuvant cancer chemotherapy, with ileostomy terminal for 15 days; identified the need to adapt the size of the equipment due to the reduction of postoperative edema ostomy. Case 3: female, 45 years old, 15 years diagnosed with Crohn's disease, has terminal ileostomy for 10 years, the patient reported that 5 years performs larger cuts of the base plate, for which said received guidance of practitioners. In all cases, there were clinical evaluation by the WOC nurse identifying contact dermatitis as a complication due to inappropriate use of equipment and ostomy supplies; the interventions were: treatment of contact dermatitis in a peristomal region, indicating adequate equipment and ostomy supplies for each patient; teaching about basic aspects of nutrition for ostomy patient (ileostomy). The WOC nurse care was essential in resolving complications such as contact dermatitis, which is a major problem in postoperative rehabilitation of these patients, as well as prevent and promote the return to activities of daily life and society.

Wound—Product Selection and Innovations



Carol Jones, CWOCN, , South Hamilton, MA

CLINICAL PROBLEM: One of the areas that insurance companies and home care agencies consider when working with wound care patients is the ability for the patient/or family to participate in wound care treatment in-between the needed skilled nurse (SN) assessment. There are often barriers to patient wound care participation, such as: 1. location of the wound; 2. limited dexterity, 3. inability to perform multiple step procedures. I looked at 5 patients between the ages of 20 and 85 years with multiple and diverse comorbidities. Their wound care was at least 3×/wk. We were using different products with a multistep procedure for each of these patients. DESCRIPTION OF PAST MANAGEMENT: Multistep wound care was more difficult for the patient/families to participate in wound care in-between their need for a SN assessment of the wound. CURRENT CLINICAL APPROACH: The goal is to enable the patient to be independent in wound care between SN home visits. Since polymeric membrane dressings (PMDs) contain continuous cleansing and a debriding system, the need for manual cleansing was eliminated. PMDs border with a transparent or cloth adhesive border, so the need for wraps/tape was eliminated. All were receptive to do their own care. Four patients and 1 caregiver were instructed in dressing changes, what to look for and when to contact trained staff with observed concerns. PATIENT OUTCOMES: All patients and caregivers found the PMDs very easy to apply, even in difficult wound locations and appropriately performed wound care. SN visits decreased from 3×/week to 1×/week and wounds closed. CONCLUSIONS: Patients who previously needed a skilled nurse to perform wound care were able to actively participate in their wound care, which resulted in increased satisfaction levels. Additionally, the agency nurses were then able to see other patients once the patients were independent with their own dressings.

Benton N, Harvath T, Flaherty-Ross M, et al. Managing chronic, nonhealing wounds. Using a research-based protocol. J Gerontol Nurs. November 2007: 38–45.

Harrison J. An independent evaluation of a new mesh-reinforced silver rope dressing. Poster presented at the 41st Annual WOC nurse Conference Poster #3332 June 6-10, 2009, St. Louis, MO.

Hurd T, Zuiliani N, Posnett J. Evaluation of the impact of restructuring wound management practices in a community care provider in Niagara, Canada. Int Wound J. 2008;5(2):296–304.

Wound—Management of Complex Wounds



Catherine Fisher, BSN, RN, CWOCN, , Karen Brooks, MSN, RN, , Leigh Kenyon, BSN, RN, , and Susan Wells, AAS, RN, , Nursing, Glens Falls, NY

CLINICAL PROBLEM: Moving wounds through the process of healing requires the removal of necrotic tissue, promotion of healthy tissue within the wound bed, moisture balance, and protection of periwound skin. Management of chronic wounds becomes a challenge when patients show no progress in their healing despite use of multiple wound care strategies, patient support, and education. Three case studies will be presented: 68-year-old male with a left lower leg venous stasis ulcer, 21-year-old male with Stage III and Stage IV pressure ulcers, and a 72-year-old female with a right lower extremity traumatic wound. The patients have various comorbidities that affect their ability to heal, and one patient has personal circumstances affecting his ability to maintain care. Each of these wounds has been present for more than 6 months leaving the patient frustrated with the lack of progress toward closure. Transition of wound management using Hydrophilic Wound Dressing (Zinc Oxide, Dimethicone, Petrolatum, and Carboxymethyl Cellulose (CMC) was implemented. PAST MANAGEMENT: Management strategies were patient specific. These included negative pressure wound therapy, enzymatic debridement, hydrogel dressings, hydrofiber silver dressings, compression therapy, and topical antimicrobial medications. CURRENT CLINICAL APPROACH: Hydrophilic wound dressing was utilized as impregnated gauze dressings to fill a deep wound or direct application to cover a shallow wound, applied periwound as skin barrier protection, and then covered with dry dressings. Dressings were changed once daily. PATIENT OUTCOMES: Hydrophilic wound dressing demonstrated effective removal of necrotic tissue, promotion of granular tissue, and protection of periwound skin. All patient wounds showed improvement as evidenced by debridement, reduction in size, and reported satisfaction with the process of wound care. CONCLUSION: Hydrophilic wound dressing is an effective wound care strategy for nonhealing wounds. Indications for use in the management of acute wounds should also be considered.

Agren MS. Zinc oxide increases degradation of collagen in necrotic wound tissue. Br J Dermatol. 1993;129:221–223.

Boyle M. Using a hydrophilic wound dressing for autolytic debridement. Poster session presented at the meeting of SAWC, Anaheim, CA, Fall 2010.

Lansdown ABG, Mirastschijski U, Stubbs N, Scanlon E, Agren MS. Zinc in wound healing: theoretical, experimental, and clinical aspects. Wound Repair Regen. 2007;15:2–16.

Moore J. Can zinc oxide have an impact on wound healing? Podiatry Today. 2003;16(9).

Morrow L. An examination of a hydrophilic zinc oxide-based paste dressing for use in difficult to dress wounds. J Wound Ostomy Continence Nurs. 2015;42(3S):18–19.

Ostomy—Product Selection and Innovations



Chizu Sakai-Imoto, RN, BSN, CWOCN, , and Jill Hammond, RN, BSN, CWOCN, , WOC Nursing, Cleveland, OH

INTRODUCTION: Pouching of large wounds and fistulae presents numerous challenges for the WOC nurse secondary to effluent, wound size and abdominal contour.1 Varying sizes of wound fistula pouches, skin barrier paste, strip paste, moldable rings, and hydrocolloid skin barriers are used to protect the skin and contain potentially caustic effluent. Using combinations of these products and various pouching systems can be costly. CLINICAL PROBLEM: Periwound/perifistular skin can become irritated from undermining of effluent and/or hydration of the pouch seal. The use of negative pressure wound therapy (NPWT) to segregate a wound from a fistula can cause the surrounding skin to depress, resulting in an uneven periwound surface, making it difficult to obtain a secure pouch seal. CLINICAL APPROACH: The “petaling” technique involves using hydrocolloid skin barriers cut into petal shapes of varying sizes and lengths.2 The petal size is determined by the contour and depth of perifistular defect that needs to be filled. Each petal overlaps the previous one, protecting surrounding skin and establishing a flat pouching surface. The petals move with the patient creating a more flexible seal. Petals are placed close to the wound border to protect periwound skin. Petals are then lightly caulked along the edge or seam with tube paste. The pouch opening is cut slightly larger than the wound/fistula border to create a sloped aperture, promoting better effluent drainage to minimize pooling and undermining. OUTCOME: Pouching large wounds or fistulae with the “petaling” technique provides improved perifistular skin protection, lengthened wear time with an enhanced flexible seal resistant to buckling and undermining. This technique is easy for colleagues and family to learn and repeat. The hydrocolloid skin barrier sheets are inexpensive in comparison with other products. This technique can be used on mushroom shaped stomas, drain sites, and other challenging pouching situations.

1. Erwin TP, Hocevar BJ, Landis-Erdman J. Fistula management. In: Colwell JC, Goldberg MT, Carmel JE eds. Fecal & urinary diversions: management principles. St. Louis, MO: Mosby; 2004:381–390.

2. Potts C, Sakai-Imoto C. Patient scenario. In: Baranoski S, Ayello EA, eds. Wound Care Essentials: Practice Principles. Ambler, PA: Lippincott Williams & Wilkins; 2012:486–488.

Wound—Product Selection and Innovations



Christopher Barrett, DPM, CWS, , Chester, PA

INTRODUCTION: There are many impediments that can affect the normal acute wound healing cascade and present as a challenge in managing chronic wounds in the clinic setting. Wound bed preparation has been defined as the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Two of the factors that need to be addressed in preparing the wound to heal are (1) addressing inflammation and bacterial bioburden and (2) managing unbalanced protease activity. Controlling wound bacterial levels prevents biofilm formation and reducing excess MMPs creates a conducive environment for the formation of granulation tissue, reepithelialization, and ultimately wound closure. METHODS/MATERIAL: An integrated 2-step approach with DACC technology and a new bioactive native collagen scaffold was used on 3 chronic wounds. The 3 patients that presented to the clinic with chronic wounds included 2 poorly controlled diabetics with dehisced first ray and hallux amputations and a noncompliant diabetic with PVD and open left TMA. DACC (dialklycarbamoyl chloride) is a fatty acid derivative that manages bacteria through hydrophobic interaction by physically binding to the cell wall, rendering them inert and thus controlling the bacterial load and reducing infection as well as inflammation. The new bioactive collagen scaffold was used to reduce excess MMPs by acting as a sacrificial substrate to protect the intact ECM, allow for new collagen deposition and neovascularization (granulation) to proceed. RESULTS: All 3 patients responded to this integrated approach as evidenced by rapid and complete wound healing with no secondary infection. CONCLUSION: Utilizing DACC to control bacterial burden and inflammation, in conjunction with a bioactive native collagen scaffold to control excess MMPs, addresses two key impediments to chronic wound healing and ultimately provides an optimum environment for wound closure.

Schultz GS, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11(suppl 1)S1–S28.

Sibbald RG, et al. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage. 2003;49(11):24–51.

Ljungh A, et al. Using the principle of hydrophobic interaction to bind and remove wound bacteria. J Wound Care. 2006;15(4):175–180.

Wound—Psychosocial and Quality of Life Aspects



Colette Allen, EdD, RN, CWOCN, , Wound Care Team, New York, NY

The term fungating wound is described as a neoplastic change of tissue structure at a tumor site. This overgrowth of cells is a rare complication of cancer, creating an abnormal protrusion through the outer layer of the skin. Fungating wounds are superficial injuries to the skin that vary in character and presentation, ranging in appearance from intact bulbous lesions to open, necrotic, bleeding ulcers resembling a cauliflower. Malodor, bleeding, edema, and excessive drainage may leave the patient with limited opportunities to self-care and a low sense of self. Heavily soiled clothing and increased odor may increase the presence of the wound and reduce social interaction. Fungating wounds can be disfiguring and painful, often requiring aggressive pain management and efforts to improve functionality of the affected site. Patients face significant stress, loss of dignity, decreased body image, and poor quality of life. Nursing management of fungating wounds demands a targeted approach to providing comfort, relieving pain, and preserving the patient's dignity. Assessing the needs of the patient will be central to planning of the care process. If pain is one of the greatest needs of the patient, it should be given high priority. However, the focus of treatment should not solely be pain control or containment of odor and drainage. Instead, the approach to care should be holistic, in that, the patient's needs should be addressed in the context of mind, body, and spirit. Specifically, the nurse will need to assess the psychosocial aspect of care by evaluating the patient's emotional and spiritual state; perception of body image; and self-care behaviors. Having an increased understanding of these factors will allow better planning and ensure meeting the patient's needs, thus providing an opportunity to improve outcomes. Three case studies focusing on psychosocial assessments of patients with fungating wounds are presented.

Adderley UJ, Holt I. Topical ointments and dressings for fungating wounds. Cochrane Collaboration. 2014:1–19.

Lo S, et al. Experiences of living with a malignant fungating wound: A qualitative study. J Clin Nurs. 2008;17(20):2699–2708.

Wound—Product Selection and Innovations



Debbie Miller, MN, RN, CETN(C), , Oncology, Toronto, ON, Canada; Barb Duncan, BScN, RN, , and Aaron Watamaniuk, BScN, RN, , Trauma Program, Toronto, ON, Canada

CLINICAL PROBLEM: A 27-year-old male was transferred to a large quaternary health sciences center in February 2015, 29 days following an out-of-country motor vehicle accident. Injuries at the time were extensive and 2 abdominal surgeries were performed in a patient with a past medical history of small bowel obstructions that required surgery. Critical care support was necessary on transfer given the patient's complex care needs, one of which included the development of 2 enteroatmospheric fistulas. PAST MANAGEMENT: The enteroatmospheric fistulas resulted in problems with containment of effluent. Frequent dressing changes were ineffective and moisture-associated skin damage occurred. The ostomy advanced practice nurse was consulted. Initial management strategies included troughing, intubating the fistulas with catheters and the use of wound managers. CLINICAL APPROACH: Negative pressure wound therapy was initiated using a “donut-ring” technique over one fistula, the second fistula was managed with a fenestrated catheter connected to low wall suction. Given this new innovative approach, detailed pictorial guides were developed. As wound closure occurred and fistula outputs decreased, a combination of ostomy products, accessory items, and advanced wound care products were introduced. PATIENT OUTCOMES: Ongoing patient assessments coupled with strong interprofessional collaboration and support ensured changes to the care plan were executed efficiently and effectively. The patient was transitioned to a rehabilitation center in June 2015. The abdominal wound had healed and the patient was independent with fistula management. His quality of life improved and he verbalized gratitude for the care received. CONCLUSIONS: Understanding best practice management of fistulas, interprofessional collaboration, detailed care plans, continuity, and ongoing support of nursing staff and patient engagement is invaluable when managing complex cases. This approach will be considered for future patients presenting with enteroatmospheric fistulas.

Di Saverio S, et al. Open abdomen with concomitant enteroatmospheric fistula: attempt to rationalize the approach to a surgical nightmare and proposal of a clinical algorithm. J Am Coll Surg. 2015;220(3):e23–e33.

Hoeflok J, Jaramillo M, Baxter N. Health-related quality of life in patients living with enterocutaneous fistulas community-dwelling persons. J Wound Ostomy Continence Nurs. 2015;42(5):1–7.

McNaughton V. Summary of best-practice recommendations for management of enterocutaneous fistulae from the Canadian Association for Enterostomal Therapy ECF Best Practice Recommendations Panel. J Wound Ostomy Continence Nurs. 2010;37(2):173–184.



Donna Willemsen, RN, BSN, CWS, CWOCN, CFCN, , Wound Care, Cedar Park, TX

PURPOSE: To demonstrate the effectiveness of dehydrated human amnion/chorion membrane in facilitating wound closure with less scarring, pain and reoccurrence in a wide variety of wound types that are not following the normal course of healing. ABSTRACT: Wound clinicians encounter a variety of chronic wounds. Patients with chronic wounds usually have comorbidities that complicate the healing cascade. The normal healing cascade includes 3 main phases—inflammation, proliferation, and remodeling. Chronic wounds stall in the inflammatory phase. Dehydrated human amnion/chorion membrane (dHACM) products serve to regenerate damaged tissue by delivering human extracellular matrix components, essential growth factors, and specialized mediating cytokines to reduce inflammation, reduce scar tissue formation, reduce pain, and enhance tissue healing. Human amniotic membrane tissue that would otherwise be discarded by hospitals as medical waste is donated through a placenta donation program. This program allows mothers, delivering healthy babies by planned Caesarean section, to donate their placentas and the processed tissues are safe, effective, and minimally manipulated allografts that are intended for homologous use. Five case studies will be presented including photos, patient histories, and progression of healing with dHACM applications. Included are the following: chronic wounds: arterial, venous, diabetic, surgical and pressure. Human amniotic membrane allografts have been used for a variety of reconstructive surgical procedures since the early 1900s. The use of amniotic membrane as an allograft has accelerated due to the development of a patented process, which allows the tissue to be dehydrated and sterilized. The result is a durable graft with natural barrier properties that offers clinicians a clear advantage in soft tissue applications. The dHACM allografts can be stored at ambient conditions for up to 5 years and come in a wide variety of sizes that make them extremely cost-efficient.

Niknejad H, Peirovi H, Jorjani M, Ahmadiani A, Ghanavi J, Seifalian AM. Properties of the amniotic membrane for potential use in tissue engineering. Eur Cell Mater. January 1, 2008;(15):88–99.

Kay H, Nelson D, Wang Y. The Placenta: From Development to Disease. Wiley-Blackwell; 2011.

John T. Human amniotic membrane transplantation: past, present, and future. Ophthal Clin N Am. 2003;(16):43–65.

Baradaran-Rafii A, Aghayan H, Arjmand B, Javadi M. Amniotic membrane transplantation. Iran J Ophthalmic Res. 2007;(2):58–75.

Wound—Evidence-Based Interventions



Emily Greenstein, CWON, , Fargo, ND

PROBLEM: Debridement of painful lower extremity wounds creates management problems for practitioners and suffering for patients. Since pain and stress can delay wound healing, strategies for reducing procedural pain and anticipatory anxiety are important factors during the course of treatment.1 Debridement and wound hygiene are a key concept in the T.I.M.E acronym for wound healing, but can be time consuming for the practitioner and create pain and anxiety for the patient.2 PREVIOUS PRACTICE: Current procedures for wound bed preparation involves topical 2% lidocaine application for 10-15 minutes followed by either scrubbing with saline soaked gauze or sharp debridement with a curette. PROPOSED SOLUTION: Through the health system's value analysis process, a soft monofilament debriding mitt (MDM) was approved for a clinical trial. A feedback form was developed to evaluate time to desired outcome, improved patient tolerance with debridement procedures, and an increase in effectiveness versus our current protocol for wound bed preparation. Painful lower extremity wounds included calciphylaxis, vasculitis, venous stasis, and arterial wounds. Clinical evaluation forms were completed by the CWON team and collected for analysis. RESULTS: Our evaluation determined that the MDM was effective in removing devitalized tissue from the wound bed and surrounding skin, as well as keratosis from the lower leg. Patients were pleased with the soft feel of the mitt and tolerate the procedures better than with previous methods. Procedural times were decreased, which supported a productivity gain that can be impactful for the value analysis process. CONCLUSION: The evaluation of an MDM showed significant benefits over our current protocol for wound bed preparation in painful lower extremity wounds. As a result of this evaluation, the wound care team will support the adoption of an MDM for wound bed preparation and continue to implement this new technology into practice.

1. Carville K, Drake R, Fletcher J, Leaper D, Schultz G, Swanson T. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J. 2012;9(suppl. 2):1–19.

2. Upton D, Solowiej K. Pain and stress as contributors to delayed wound healing. Wound Pract Res. 2010;18(3):114–122.

Wound—Product Selection and Innovations



Ferne Elsass, MSN, RN, CPN, CWON, , Norfolk, VA

PROBLEM: Complex wounds such as deep pressure ulcers, epidermolysis bullosa, sternal wounds following cardiac surgery, and wounds in immunocompromised patients require multiple modalities to advance the wound to a healing trajectory. Surgical correction of the wound with techniques such as pedicle or free flaps is often not possible because of the overall condition of the patient. Even surgical debridement may be contraindicated in the most severely ill patients. METHODS: Because the eschar presenting on most of these wounds is dry, medical-grade honey has been a mainstay of our nonsurgical debridement. Recently, we have added hypochlorous acid* irrigation and soaks to the wounds. We have used this treatment in a series of 9 patients with a total of 13 wounds. RESULTS: The hypochlorous acid treatment not only served as an adjunct to debridement, but also accelerated the wounds in leading to a healing trajectory. Once debridement was complete, continued soaks of hypochlorous acid lead to rapid complete healing of the wounds. In the patients with the major wounds, the hypochlorous acid was also used to cleanse around tracheostomy sites and gastrointestinal tube egress sites with successful healing of any macerated or denuded skin. Selected examples of the 9 patients will be presented in the poster. CONCLUSIONS: Hypochlorous acid proved to be adjunctive to debridement in 9 patients with 13 wounds. The continued use following debridement lead to a healing trajectory in these complex wounds in children.

*Vashe Wound Cleanser, SteadMed Medical LLC, Fort Worth, TX.

Couch KS, Miller C, Cnossen LA, Richey KJ, Ginn SJ. Non-cytotoxic wound bed preparation: Vashe hypochlorous acid wound cleansing solution. Wound Source White Paper, September 2015.

Miller C, Mouhlas A. Significant cost savings realized by changing debridement protocol. Ostomy Wound Manage. 2014;60(9):8–9.

Wound—Management of Complex Wounds



Idevania Costa, RN, BScN, MN, PhD (Student), , School of Nursing, Kingston, ON

INTRODUCTION: Complex wound is the term used more recently to identify those chronic wounds or even some acute wounds that despite being well-known, challenge medical and nursing teams (Ferreira, Tuma, Fernandes, & Kamamoto, 2006; Vowden, 2011). AIM: To present the management of complex wounds implemented by an interdisciplinary team in a wound care ambulatory. METHODS: Prospective description of clinical cases of patients with complex wounds managed in a South America Country, between November 2011 and March 2012, after approval of a Research Ethics Committee (No. 2011/139). The criteria to select the dressing to the management of complex wounds were: availability of the products/dressing, patients' preference, etiology and characteristics of the wound and knowledge and skills of the professionals. Thus, considering the criteria above the products and dressing used were the following: (1) alginate associated to coal dressing; (2) alginate dressing alone; (3) papain-based paste; and (4) compression therapy. The conservative sharp debridement was associated with an enzymatic debridement performed by a wound-care nurse. RESULTS: Six patients were selected, 4 (66.7%) were female and 2 (33.3%) males, aged ≥ 60 years and retired (66.7%) and aged < 60 years and working on trade (33.3%). Regarding the etiology of complex wounds, 3 (50%) were venous ulcers, 2 (33.3%) were neuropathic ulcers and 1 (16.7%) ulcer due to dermal reaction to the treatment of leprosy in a patient with diabetes mellitus. The healing process was resolved at 4 months in the majority of the cases (66.7%) with 2 cases (33.3%) healing in 2 months and 3 months, respectively. CONCLUSIONS: Assessment of the patient, identification of the underlying causes, availability of the dressing and patients' preference as well as considerations of competency, skills and access to a reference service are essential to the success of the management of complex wounds in a developing country.

Ferreira MC, Tuma P Jr, Fernandes CV, Kamamoto F. Complex wounds. Clin. 2006;61(6):571–578.

Vowden P. Hard-to-heal wounds: made easy. Wounds Int. 2011;2(4):1–5.



Idevania Costa, RN, BScN, MN, PhD (Student), , School of Nursing, Kingston, ON

INTRODUCTION: Wound bed preparation (WBP) is the process of converting chronic wound into a healing wound.1 The goal of wound bed preparation is to eliminate the barriers to healing and successfully achieve repair process. However, it is not “a piece of cake” because some acute wounds usually fail to progress through all 4 phases of healing and get “stuck” in a persistent inflammatory stage and become chronic.2 AIM: To evaluate case studies of chronic wounds after incorporating the principles of wound bed preparation and TIME acronym in a formulary to assess and monitor the healing process of wounds that had failed to heal. METHODS: A prospective study of patients with chronic wounds was developed by the author in a Reference Centre for complex wounds in Brazil between November 2012 and March 2013, after approval of an Ethics Committee in Research (No. 2011/139). The evolutions were undertaken using an updated formulary to assess the healing process by incorporating the principals of wound bed preparation and TIME acronym as well as products and dressings to resolving the local barriers. RESULTS: The patient population was composed of 22 patients, being 9 (41%) males and 13 (59%) females, with an age range between 15 and 74 years. The main type of the wound were leg venous ulcers (41%) following by diabetic foot ulcers (14%), leprosy ulcers (14%) and others types (31%). The wound bed preparation occurred in the majority of the cases within 4 weeks (63%) after stating the systemic and local treatment. The time to heal all wounds ranged between 2 to 4 months. CONCLUSION: The principles of wound bed preparation associated with the TIME-based treatments(2) provides a structured approach to the management of chronic wounds, which are the keys to effective wound care and improvement of the outcomes.

1. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Rep Reg. 2003;11(suppl 1):S1–S28.

2. Schultz G, Dowsett C. Technology updated: wound bed preparation revisited. Wounds Int. 2012;3(1):25–29.

Ostomy—Stomal/Peristomal Complications



Janaína da Silva, MSN, BSN, RN, , Ribeirão Preto, Sao Paulo, Brazil, and Rosana Frazatto Pedroso, Nursing student, , Ourinhos, Sao Paulo, Brazil

INTRODUCTION: Stomal and peristomal complications in adults result in clinical condition, treatment, and absence of preoperative stoma site marking, compromising rehabilitation. CLINICAL PROBLEM: Case Study 3 patients, not stoma site marked with complications of stoma and peristomal postoperative, with difficulties in adaptation of Pouching system and were attended by WOC nurse. Case 1: 75, female, with mucocutaneous separation, peristomal irritant contact dermatitis, pain and 3 daily changes of pouching system in ileostomy from metastatic colorectal cancer. Case 2: 68, male, peristomal irritant contact dermatitis and pain, with more than 2 daily changes of colostomy pouching system by chagas megacolon. Case 3: 45, female, with peristomal irritant contact dermatitis and pain, with more than 4 daily changes of pouching system in ileostomy from colorectal cancer. INTERVENTION: We used hydrofiber dressing with silver, paste, and protective skin barrier during 1 month with the use of precut convexity pouching system and belt (cases 1, 2, and 3), with teaching self-care (stoma and pouching system) for the patient and family by WOC nurse. RESULTS: There was complete healing of mucocutaneous separation, peristomal irritant contact dermatitis and improve pain in 3 weeks, with pouch changes every 4 days (case 1), every 5 days (cases 2 and 3). CONCLUSIONS: The specialized educative intervention from WOC nurse with indication of pouching system for the patient, use of hydrofiber dressing with silver and paste resulted in wound healing, self-care learning and resumption of daily activities for patients and families.

Takahashi K, Funayama Y, Fukushima K, et al. Stoma related complications in inflammatory bowel disease. Dig Surg. 2008;25:1–20.

Gray M, Colwell J, Doughty D, et al. Peristomal moisture-associated skin damage in adults with fecal ostomies. J Wound Ostomy Continence Nurs. 2013;40(4):389–399.

Wound—Preventative Practices New



Marco Antonio da Silva Freitas, , Evil Merodaque Decol, and Rosana Frazatto Pedroso, Nursing student, , Ourinhos; Janaína da Silva, MSN, BSN, RN, , Ribeirão Preto; Camila Megumi Naka Shimura, PhD Student, CWOCN, BSN, RN, , School of Nursing at University of São Paulo, Ribeirão Preto/São Paulo, Brazil

INTRODUCTION: Chronic venous insufficiency is responsible for more than 50% cases of lower extremity wounds in Brazil. This is a problem of public health. The chronic venous ulcers is consequence of venous insufficiency mainly together with excessive drainage result in pruritus, pain, periwound maceration, and swelling leg. CLINICAL PROBLEM: Case Study 3 patients with chronic venous ulcers for a long time, all of the wounds displayed delayed or stalled healing and were attended by WOC nurse. Case 1: 45, female, diabetic foot and venous insufficiency, deep wound and necrosis in finger. It was needed the amputation, a little pain, swelling leg and difficulty for walking by 2 years. Case 2: 65, female, chronic venous wounds, strong pain, pruritus, excoriation and swelling leg by 8 years. Case 3: 68, male, with chronic venous wound, pain and swelling leg by 5 years. INTERVENTION: We used hydrofiber dressing with silver, protecting the periwound skin barrier like creams and ointments, mechanic debridement and compression wraps, during 6 months, with teaching self-care (like physics activity, alimentation, wound care) for the patient by WOC nurse. RESULTS: There was complete healing of chronic venous ulcers, swelling leg and improve pain in 3 weeks, all the patients. The patient case 1 did not use the compression wraps because she had diabetic foot. CONCLUSIONS: The specialized nursing intervention from WOC nurse with indication of treatment for the patient, use of hydrofiber dressing with silver and compression wraps resulted in wound healing, autoesteem improving and resumption of daily activities for patients and preventing after healing a new wound.

Abbade LP, Lastoria S. Venous ulcer epidemiology, physiopathology, diagnosis, and treatment. Inter J Dermatol. 2005;44(6):449–456.

Pieper B. Honey-based dressings and wound care: an option for care in the United States. J Wound Ostomy Continence Nurs. 2009;36(1):60–68.

Ostomy—Product Selection and Innovations



Jill Hammond, RN, BSN, CWOCN, , and Chizu Sakai-Imoto, RN, BSN, CWOCN, , WOC Nursing, Cleveland, OH

INTRODUCTION: The development of a fistula presents physical and psychological management difficulties for the patient. The patient and family frequently request immediate surgical intervention. Researchers have discovered that fistula recurrence after take down surgery is much lower in individuals who wait at least 6 months for the repair.1 In the interim, the WOC nurse serves a pivotal role within a multidisciplinary team in managing the fistula during this transitional period.2 CLINICAL PROBLEM: A 64-year-old female with a history of Crohn's disease, multiple abdominal surgeries, and ileostomy developed wound dehiscence with intra-abdominal sepsis and fistulae after a cholecystectomy and hernia repair. She developed sepsis during her hospitalization, requiring additional surgical intervention to drain an abscess and extended wound debridement. Postsurgical WOC nursing challenges included a large wound, unfavorable fistulae location, obesity, high volume output, multiple pouched sites, and frequent pouch leakage. CLINICAL APPROACH: Comprehensive clinical management included developing a complex pouching system consisting of a large fistula pouch with “petaling” technique of hydrocolloid skin barrier wedges.3 Appropriate pouching system with “petaling” offers enhanced perifistular skin protection and stability of soft abdominal contours. Additionally, containment of effluent, odor control and strict monitoring for intake and output was achieved. OUTCOME: During her 8-month waiting period for surgery, WOC nurses successfully managed the complex “petaled” fistula pouching system to obtain a 4-day wear time while maintaining intact perifistular skin. She was taken for fistula closure with diverting loop jejunostomy. Three months later, the stoma was reversed and she recovered without complications. In conclusion, the “petaling” technique contributed to better wound/fistula management with increased mobility and overall physical and psychological satisfaction.

1. Lynch AC, Delaney CP, Senagore AJ, Connor JT, Remzi FH, Fazio VW. Clinical outcome and factors predictive of recurrence after enterocutaneous fistula surgery. Ann Surg. November 2004;240(5):825–831.

2. Orangio GR. Enterocutaneous fistula: medical and surgical management including patients with Crohn's disease. Clin Colon Rectal Surg. 2010;23(3):169–175.

3. Potts C, Sakai-Imoto C. Patient scenario. In: Baranoski S, Ayello EA, eds., Wound Care Essentials: Practice Principles. Ambler, PA: Lippincott Williams & Wilkins; 2012:486–488.

Wound—Management of Complex Wounds



JoAnn Ermer-Seltun, MS, ARNP, FNP-BC, CWOCN, CFCN, , Minneapolis, MN

PROBLEM: Complex refractory wounds impose physical, psychological, and monetary burden that negatively impacts the quality of life and healthcare resources.1 Research has enhanced the acceptance of HBOT as an adjunctive therapy to treat refractory wounds.2 PAST: A Midwest outpatient wound center established 1999 without HBOT, utilized a team approach to coordinate the management of patients with chronic wounds. Patients needing adjunct HBOT had to be referred to another AWC over 1-hour away. CONSEQUENCES: patients lost to another health system, palliation of care, wound deterioration leading to hospitalization or even limb loss. CURRENT: 2 monochambers were added in 2011. Patient selection process followed the Undersea and Hyperbaric Medical Society's guidelines. HBOT was discontinued if intolerant to treatment, failure to respond to adequate trial, or inability to follow the plan of care. OUTCOMES: A total of 69 patients initiated HBOT from 10/2011 through 10/2015. Mean age was 57 years, 36 males, 33 females with 34 mean number of dives. Thirty-three patients (48%) attained complete wound closure at the end of HBOT, 15 (22%) wounds improved significantly but did not fully close, 3 patients aborted treatment due to transportation or financial issues, 3 aborted due to medical issues, 6 patients transferred care: 4—surgical repair, 1—amputation, 2—closer HBO facility. Patient diagnosis included: 32 (46%) Wagner Grade 3 DM foot ulcers, 18 (56%) healed; 12 (17%) chronic osteomylitis without DM; 10 (15%) compromised skin graft; 8 (12%) soft tissue radionecrosis, 3 (4%) osteoradionecrosis; 3(4%) wound hypoxia, and 1 fistula due to Crohn's. Manageable adverse events: inability to clear ears (7 (10%) needing pressure equalizer tubes), low blood sugars, and anxiety. CONCLUSIONS: Adjunct HBOT appears to promote healing especially in patients with Wagner grade 3 DM foot ulcers. This case series supports previous research that HBOT is an effective and safe adjunct to refractory wound healing and limb salvaging.3,4

1. Netsch D. Refractory wounds: assessment and management. In: Doughty DB, McNichol LL, eds. WOC nurse Core Curriculum: Wound Management. New York, NY: Wolters Kluwer; 2016.

2. Warriner AW, Wilcox JR, Barry R. The role of oxygen and hyperbaric medicine. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014.

3. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic HBOT in treatment of severe prevalent ischemic diabetic foot ulcer. A randomized study. Diabetes Care. 1996;19(12):1338–1343.

4. Kranke P, et al. HBOT for chronic wounds. Cochrane Database Syst Rev. 2004;(2):CD004123.

Ostomy—Continent Diversion Issues



Karen Simmons, MSN, RN, CWOCN, , Wound Ostomy, Temple, TX

BACKGROUND: In the 1960s, a patient requiring proctocolectomy surgery for ulcerative colitis or Crohn's Disease needed a permanent ileostomy.3,4 A continent ileostomy pouch developed in 1967 by Dr Nils Kock gave patients another option.4 After surgery, a patient would intubate the stoma with a catheter to evacuate the pouch 3-4 times daily.3 By 1980, this procedure was replaced by the ileal pouch anal anastomosis continent diversion commonly seen today.1,2,5 STATEMENT OF CLINICAL PROBLEM: A 55-year-old female patient with Crohn's disease and a Kock pouch since 1978 was diagnosed with liver cancer. She required a liver resection immediately. The nurse practitioner, unfamiliar with the Kock pouch, consulted the certified WOC nurse to develop a plan of care. DESCRIPTION OF PAST MANAGEMENT: Literature to guide the care of this patient was limited. She felt strongly that nurses would fail to keep the pouch decompressed without a plan. She would spend several days in the intensive care unit intubated and unable to care for the pouch herself. She knew that the pouch was rare and feared nurses' lack of knowledge related to continent ileostomy care may cause untoward events. CURRENT CLINICAL APPROACH: In order to keep the continent ileostomy stoma intubated during surgery and postoperatively, a 2-piece ostomy pouch, a 28 French urology catheter, suture and pink tape were used. The suture was tied around the catheter and attached between the flange of the ostomy pouch at 3 and 9 o'clock. The tape was placed on the tube at the os of the stoma, which prevented movement of the catheter. PATIENT OUTCOMES: The catheter drained into the ostomy pouch. The continent ileostomy did not become distended. This system remained intact 5 days until the patient was able to intubate the stoma. CONCLUSIONS: While the patient was incapacitated, this method worked seamlessly.

1. Beck DE. Continent ileostomy: current status. Clin Colon Rectal Surg. 2008;21(1):62–70.

2. Colwell JC, Goldberg M, Carmel J. The state of the standard diversion. J Wound Ostomy Continence Nurs. 2001;(28):6–17.

3. Doughty DB. History of ostomy surgery. J Wound Ostomy Continence Nurs. 2008;35(1):34–38.

4. Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy. Arch Surg. 1969;(99):223–231.

5. Nessar G, Wu JS. Evolution of continent ileostomy. World J Gastroenterol. 2012:18(27):3479–3482.

Wound—Management of Complex Wounds



Katherine Lincoln, DO, , Killeen, TX

Various treatment options exist for wound healing; however, evaluation of the wound environment and factors that impair wound healing need to be considered before selecting appropriate therapy. Here, we present a case series demonstrating successful wound closure using advanced wound treatments: collagen/oxidized regenerated cellulose/silver (C/ORC/S) dressings, negative pressure wound therapy (NPWT), and epidermal skin grafts harvested with an automated epidermal harvesting system. Patient 1 was a 28-year-old female who presented with a left knee pressure ulcer complicated by transverse myelitis, quadriplegia, poor nutrition, and diabetes. Following daily application of a debriding agent for 3 weeks, an epidermal skin graft was harvested and transferred to the recipient site using a nonadherent silicone dressing. At 1 week postepidermal graft application, the wound healed and the patient was discharged. Patient 2 was a 63-year-old male, with a history of diabetes, ischemic stroke, and right-side paralysis, who presented with a left heel wound due to deep ulceration and emergency calcanectomy. Management consisted of 3 weeks of continuous NPWT at −150 mmHg and offloading. NPWT was discontinued, and C/ORC/S dressings were applied to the wound for 13 weeks. After sufficient granulation tissue formation, epidermal grafts were applied over the wound, which closed at 4 weeks postepidermal graft application. Patient 3 was a 71-year-old female with mild dementia who presented with a sacral pressure ulcer as a result of prolonged toilet sitting. Treatment was initiated with daily application of a debriding agent for 3 weeks followed by 3 weeks of continuous NPWT at −150 mmHg. NPWT was discontinued and C/ORC/S dressings were applied three times a week. Wound closure was observed 12 weeks post-C/ORC/S application. In all three cases, adjunctive use of advanced wound care treatments positively affected the clinical outcome.

Wound—Product Selection and Innovations



Kimberly LeBlanc, MN, RN, CETN(C), PhD (student), , Nursing, Kingston, ON, Dawn Christensen, MHSc(N), RN, CETN(C), , Enterostomal Therapy, Ottawa, ON, Canada, and Vida Johnston, BScN, RN, WOCN, CAET (C), , Nursing, Ottawa, ON, Canada

Skin tears (STs) are prevalent acute wounds found in the elderly population with a high propensity to become complex and chronic wounds, which in turn delays wound healing. The associated fragile periwound skin complicates dressing selection for individuals suffering from STs. In recent literature, there has been an increase in the attention given to these wounds, however there has been no gold standard for the management of these wounds. Through case study format this poster will present an evaluation of one treatment option available for STs. METHOD: A convenience sample of 10 subjects (age > 65) living in a Long-term Care facility presenting with type 2 and 3 STs were treated with a Methylene Blue and Gentian Violet Dressing, a nontraumatic topical dressing which has been affectively used to treat other complex wounds. Wound healing time, dressing cost, patient satisfaction, and pain associated with the dressing were recorded for each individual. FINDINGS: Complete closure in 10 out of 10 wounds within 4 weeks with an average of 2 dressing changes per week. Subjects denied pain with application. Registered staff reported no problems encountered with the dressing use and noted increased patient comfort. Cost per application was estimated to be $12.00 (CAN)/application based on unit price. CONCLUSION: Through case study format, this poster highlighted an economical and effective method for treating type 2 and type 3 STs in the elderly population living in long-term care; however, these results may not be generalizable to other populations. The results demonstrate the need for further research into the wound healing benefits of Methylene Blue and Gentian Violet dressings in the treatment of STs and its cost-effectiveness.

Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G. The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. Int Wound J. 2014;11(4):446–453. doi:10.1111/iwj.12326

LeBlanc K, Baranoski S. Skin tears: the forgotten wound. Nurs Manage. 2014;45(12):36–46.

LeBlanc K, Baranoski S, Christensen D, et al. State of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9):2.



Kimberly LeBlanc, MN, RN, CETN(C), PhD (student), , Nursing, Kingston, ON, Canada, Dawn Christensen, MHSc(N) RN CETN(C), , Enterostomal Therapy, Ottawa, ON, Canada, and Vida Johnston, BScN, RN, WOCN, CAET (C), , Nursing, Ottawa, ON, Canada

Skin tears (STs) are prevalent acute wounds found in the elderly population. The associated fragile periwound skin complicates dressing selection for individuals suffering from STs. In recent literature there has been an increase in the attention given to these wounds; however, there has been no gold standard for their management. Through case study format, this poster will present an evaluation of one treatment option available for STs. METHOD: A convenience sample of 20 individuals (age > 65) living in a long-term care facility presenting with type 1 or 2 STs of less than 4 hours' duration were treated with a 2-Octylcyanoacrylate Topical Bandage. Wound healing time, dressing cost, patient satisfaction, and pain associated with the dressing change were recorded for each individual. FINDINGS: Complete closure in 20 out of 20 wounds in 2 weeks with 1 application of 2-Octylcyanoacrylate Topical Bandage. Patients denied any pain with application. There were no signs and symptoms of infection at wound sites. Registered staff reported no problems encountered with the application of product and reported decreased nursing time required for wound care (approximately 5 minutes per wound) and increased patient comfort. Cost per application was estimated to be $5.00 (CAD)/application based on unit price. An added benefit reported by staff included that with the use of the 2-Octylcyanoacrylate Topical Bandage, patients were less likely to scratch and pick at wound site. CONCLUSION: Through case study format, this poster highlighted one economical and effective method for treating type 1 and 2 STs in the elderly population living in long-term care; however, due to the small sample size, these results may not be generalizable. The results demonstrated the need for further study into the wound healing benefits of 2-Octylcyanoacrylate Topical Bandage in the treatment of skin tears and its cost-effectiveness.

Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G. The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. Int Wound J. 2014;11(4):446–453. doi:10.1111/iwj.12326.

LeBlanc K, Baranoski S. Skin tears: The forgotten wound. Nurs Manage. 2014;45(12):36–46.

LeBlanc K, Baranoski S, Christensen D, et al. State of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9):2.



Lauren Wolfe, BSN, RN, CWOCN, , Home Health, Vancouver, BC, Canada

The prevalence of heel pressure ulcers in one study within the orthopedic population ranges from 9% to 19%.1 To prevent heel pressure ulcers, the National Pressure Ulcer Advisory panel recommends to “Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows.”2 This poster cites 4 case studies where the use of an easy-to-use, safe, and cost-effective heel suspension device contributed to wound healing. #1: 68-year-old female Home Health patient with multiple sclerosis presented with a stage 2 pressure ulcer on her left heel. Complete healing occurred by week 10 using moist wound healing and a heel suspension device. #2: 74-year-old female in a residential care facility with an unstageable pressure ulcer on her left heel. Complete closure occurred in 12 weeks utilizing moist wound healing and a heel suspension device. #3: 70-year-old male with vascular compromise developed a Stage 4 heel pressure ulcer postrevascularization. Utilizing moist wound healing, surgical debridement, and a heel suspension device the wound healed in 6 months. #4: 83-year-old male in a residential care facility with bilateral stage 4 pressure ulcers. Utilizing moist wound healing, conservative sharp wound debridement and a heel suspension device these wounds healed despite a maintenance goal. Heel pressures ulcers are prevalent across the continuum of care. Suspending the heels off the bed utilizing a heel suspension device aids in healing of pressure ulcers. Decreasing the incidence and prevalence of pressure ulcers requires the offloading device to be easy to use, safe, and cost-effective.

Campbell K, Woodbury G, Houghton P. Heel pressure ulcers in orthopedic patients: a prospective study of incidence and risk factors in an acute care hospital. Ostomy Wound Manage. 2010;56(2):44–54.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014.

Ostomy—Product Selection and Innovations



Lauren Wolfe, BSN, RN, CWOCN, , Home Health, Vancouver, BC, Canada

Peristomal skin complications range from 6 to 80%. When an ostomate experiences skin issues, it becomes a challenge for the patient and enterostomal nurse (ET). Skin complications decrease wear time, leads to frustration, negatively impacts quality of life, and creates financial burdens. Studies have shown that ceramide is a building block of healthy skin. This poster will demonstrate how the addition of a ceramide-infused barrier has shown positive outcomes for 4 ostomy patients. #1: 61-year-old female paraplegic with colostomy and ileal conduit presented with denuded peristomal skin to her colostomy at the mucocutaneous junction. Previous product included a moldable barrier and adhesive remover. A ceramide-infused barrier was applied with complete healing in 8 weeks. #2: 26-year-old male with loop colostomy, small parastomal hernia and sensitive skin presented with peristomal erythema and papules around the entire stoma. No leakage. Ceramide infused barrier applied with complete healing. #3: 80-year-old female with ileal conduit present 2 weeks postoperatively with a rash to her peristomal skin. Using aloe gel, skin protective wipe and barrier ring. Ceramide-infused barrier was applied after removing all barrier wipes she had complete healing. #4: 73-year-old male with ileal conduit, large parastomal hernia and eczema presented with dermatitis to peristomal skin due to constant leakage. Ceramide-infused barrier applied in combination with a barrier ring, belt and protection from tape, improvement was noted by day 16. CONCLUSIONS: Peristomal breakdown is challenging for the ostomate and ET. Ceramide barriers have shown positive outcomes for the ET and patient. This poster represents only 4 individual case studies. Additional studies would be needed to determine the impact ceramide infused barriers have on peristomal skin health. The 4 case studies demonstrated improved outcome for these patients.

Kurian A, Barankin B. Therapeutic moisturizers in eczema and xerosis management. Skin Ther Lett. 2010;5:1–3

Nybaek H, Lophagen S, Karlsmark T, Bang Knudsen D, Jemec GBE. (). Stratum corneum integrity as a predictor for peristomal skin problems in ostomates. Br J Dermatol. 2010;162(2):357.

Richbourg L, Thorpe JM, Rapp CG. (2007, January-February). Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs.

Wound—Management of Complex Wounds



Lawrence DiDomenico, DPM, , Youngstown, OH

Diabetic foot complications are a major threat to public health. Loss of protective sensation from peripheral neuropathy and arterial insufficiency, among many other factors, can cause diabetic foot ulcers (DFU). Wound healing can be improved by various treatments, but many dynamics need to be considered before proceeding with appropriate therapy selection. Early patient and wound assessment along with aggressive treatment by a multidisciplinary team represent the best approach to managing high-risk diabetic patients. Examining the patient as a whole is necessary to evaluate and correct causes of tissue damage. My purpose is to review fundamentals of good clinical wound care for managing patients with DFUs and present cases using 3 advanced treatment options. Patient 1 was a 42-year-old male who presented with a necrotic foot. Following debridement and amputation of the third digit, negative pressure wound therapy was applied for 20 days. After sufficient granulation tissue formation, patient returned to surgery for an amputation of the fourth digit and a split-thickness skin graft. At 1-year follow-up, the foot was fully recovered, plantigrade, and functional. Patient 2 was a 70-year-old male who presented with a nonhealing DFU. Extensive debridement was performed, followed by application of a collagen/oxidized regenerated cellulose/silver matrix dressing and offloading. At 3-month follow-up, DFU was fully closed. Patient 3 was a 65-year-old male who presented with a DFU caused by a complication from previous surgery. Silver nitrate was used to address hypergranulation tissue, and then epidermal grafts harvested with an epidermal harvesting system were applied over the DFU. At 3 weeks postgrafting, DFU was reepithelialized with no complications. In all 3 cases, the use of advanced therapies in conjunction with good wound care positively affected closure of these difficult wounds.

Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg. 2010;52(3) (suppl), 17S–22S.

Steed D. Modulating wound healing in diabetes. In: Levin and O'Neal's The Diabetic Foot. St. Louis, MO: Mosby; 2001.

Sibbald R, et al. Preparing the wound bed: debridement, bacterial balance, and moisture balance. Ostomy Wound Manage. 2000;46(11):14–28.



Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, , Clinical Education, Austin, TX

PROBLEM: An otherwise healthy 55-year-old man (pseudonym “Ray”) underwent palliative flap-graft surgery postterminal sacral sarcoma removal and was left with two (3 × 2.3 × 1.4 cm, and 1.1 × 0.8 × 0.5 cm with circumferential 0.5 cm undermining and exposed bone) nonhealing left trochanter wounds. Ray's family dressed his wounds, guided by wound clinic physicians and home health. Despite chemotherapy, Ray struggled to maintain his modest masonry business. PAST MANAGEMENT: Nine months of no improvement with negative pressure wound therapy (NPWT) on the larger, heavily exudating, cavity wound and silver hydrofiber on the wound with the exposed bone led to frustration and weariness. NEW CLINICAL APPROACH: Wound management was changed to adhesive-bordered polymeric membrane dressings (PMDs) with silver PMD wound filler for the wider cavity wound and silver PMD rope for the narrower wound. Dressing changes were easier, quicker, and pain-free: the saturated PMDs were simply removed and replaced without rinsing. These continuously cleansing dressings allayed fears of infection and set Ray free of “the machine.” PATIENT OUTCOMES: Without NPWT, Ray was able to sleep well for the first time in 9 months. Inflammation subsided. At job sites, Ray could safely ignore his wounds. Surprisingly, despite chemotherapy, both wounds granulated quickly, closing completely within 7 months. Ray enjoyed ∼8 wound-free months before the tumor recurred, growing rapidly. The flexibility, cuttability, and elasticity of PMDs proved especially helpful in dressing the inoperable rapidly growing (maximum ∼20 × 20 × 10 cm) protrusion to prevent infection. Nonadherent PMDs so completely controlled the bleeding and odor usually accompanying large fungating wounds that visitors were not distracted by Ray's large tumor, even in his final days. CONCLUSIONS: Ray benefited from the many unique attributes of PMDs working together in his 3 very different wound types: a heavily exudating wound, a narrow wound with exposed bone, and a large fungating tumor, dramatically improving the final 16 months of Ray's life.

Benskin LLL. PolyMem® Wic® Silver® Rope: a multifunctional dressing for decreasing pain, swelling, and inflammation. Adv Wound Care. 2012;1(1):44–47.

Langemo DK, Black J National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010;23(2):59–72.

Wound—Product Selection and Innovations



Loren C. Hayes, DNP, MS, ARNP, GNP-BC, GCNS-BC, CWCN-AP, CFCN, CWS, , Clinical, Hollywood, FL

OBJECTIVE: To discuss the clinical benefits of utilizing an integrated solutions approach to treatment of venous leg ulcers utilizing a bacterial binding dressing, a native bovine collagen product and compression in an aging population. THE CHALLENGE: The aging population and prevalence of multiple comorbidities complicate the care of patients with venous leg ulcers. This scenario is further complicated by the microenvironment of the chronic wound, the need for compression and the importance of collagen in wound healing. This population often has some level of arterial insufficiency, where utilization of traditional multilayer wraps is inappropriate. THE SOLUTION: A series of 6 elderly patients with venous leg ulcers were evaluated where conventional therapies and compression had not proven effective. Each wound bed was prepared with a bacterial binding dressing and a 2-layer compression system. The prepared wound bed was then ready to accept a bovine collagen product comprised of 90% Bovine Collagen (Types 1, 3, and 5) which mimics the structure of human dermis, and 10% alginate, which stimulated Type 4 Collagen for formation of the basement membrane and scaffolding. RESULTS: Treatment of venous leg ulcers in an aging population with a prevalence of multiple comorbidities and often times, arterial insufficiency was addressed. This scenario was further complicated by the microenvironment of the chronic wound, the need for appropriate compression and the requisite for a product to form the basement membrane and to act as a scaffold for new cells to cleave. The use of an integrated solutions approach utilizing a bacterial binding dressing, a bovine collagen product, and a 2-layer compression system designed for patients with arterial insufficiency, demonstrated effective in this difficult population. Outcomes included improved patient compliance with compression, established granulation, reduced wound volume and area, no incidence of infection, and self-report of diminished pain.

Brett D. A Review of Collagen and Collagen-based Wound Dressings. Wounds. 2008;20(12).

Cutting K, et al. J Wound Care. 2015; 24(5).

Cutting K, et al. J Wound Care. 2011;20(5):1–19.

Fan D, et al. Cardiac fibroblasts, fibrosis and extracellular matrix remodeling in heart disease. Fibrogenesis Tissue Repair. 2012;5:15.

Ljungh A, et al. Using the principle of hydrophobic interaction to bind and remove wound bacteria. J Wound Care. 2006;15(4):175–180.

Wound—Management of Complex Wounds



Lori Ormsby, APRN, CNS, CWOCN, CFCN, , Tulsa, OK, and Lam Le, MD, CWSP, FACHM, , Broken Arrow, OK

Total contact casting (TCC) has been shown to increase healing of patients with diabetic foot ulcers and is considered the gold standard for off-loading and ulcer management. Taking pressure off a wound is key to closure, but TCC is an underutilized modality. Caregivers erroneously believe casting is time consuming, difficult to apply and remove. This poster will describe 3 patients with unique and challenging anatomy and diagnoses, not limited to diabetes that quickly healed with aid from casting. A roll-on total contact cast was used to treat R.F., a 68-year-old male with diabetes and no comorbidities, admitted to the clinic following hospitalization for cellulitis of the foot related to an ulcer. The patient had had no specific wound care or offloading for 6 months. A cast was placed on the second visit and changed twice weekly. The wound closed in 4 weeks. Due to neuropathy and subsequent drop foot, a traditional contact cast was used to treat P.W., an 80-year-old nondiabetic female with a stage 4 pressure ulcer to the lateral aspect of her foot. With 7 weeks of advanced wound care and off-loading prior to admission, the wound failed to progress. Subsequently, a cast was placed weekly to relieve pressure to the area and provide a walking surface. A bioskin equivalent was also placed on the wound, and after 14 weeks the wound closed. A traditional contact cast was also utilized to treat L.N., a 48-year-old female with uncontrolled diabetes, Charcot joint, recurring bilateral foot ulcers and multiple toe amputations. Her weight and foot structure made off-loading with standard shoes difficult. Faced again with treating simultaneous wounds, and not wanting to sacrifice 1 foot to heal the other, she agreed to bilateral casting. With advanced wound care and weekly cast changes, both wounds were healed in 7 weeks.

Snyder RJ, Frykberg RG, Rogers LC, Applewhite AA, Bell D, Bohn G. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014;104(6):555–567.

Armstrong DG, Nguyen H, Lavery L, Van Schie C, Boulton A, Harkless L. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24(6):1019–1022.



Marcus Speyrer, RN, CWS, , and Kerry T. Thibodeaux, MD, FACS, , Opelousas, LA

Skin grafting is often utilized for wound closure in complex, nonhealing wounds. Grafting using split-thickness skin grafts (STSGs) require anesthesia, a surgeon, and an operating room. Healing complications of STSGs can include graft failure, graft contraction, and scarring.1,2 A commercially available epidermal harvesting system removes the epidermal skin layer for grafting and can be used without anesthesia in the office or at the patient's bedside. Here, we examine the use of epidermal grafting in patients with complex, nonhealing wounds at a wound care center. The patients' thighs were prepared with hair removal and washed with 70% ethanol. The epidermal harvesting system was attached and applied negative pressure (−400 mmHg to −500 mmHg) and heat (37°C to 41°C) for approximately 30 minutes to raise epidermal micrografts. The micrografts were harvested on to a silver-impregnated foam dressing and transferred to the wound. Donor sites were covered with self-adherent absorbent foam dressing. Wound reepithelialization was monitored at each follow-up visit. Four patients presented to the wound care center between May and August 2015. Three females and one male (ages ranging from 15 to 82 years old) were included in the study. The patients presented with complex, nonhealing wounds from a dog bite, pressure ulcer, traumatic injury, or cancer excision. Patient comorbidities included hypertension, knee replacement, pacemaker, and melanoma of the lower extremity. Prior to receiving epidermal grafts, the wounds were debrided and, in 2 patients, treated with negative pressure wound therapy. All wounds healed without complications between 4 and 8 weeks postepidermal grafting. All donor sites healed without complications. In these patients, epidermal grafting promoted wound healing without complications. As such, epidermal grafting offers a viable alternative to STSG for wound closure that does not require anesthesia and can be performed in the office or at the bedside.

1. Salome GM, Blanes L, Ferreira LM. The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers. World J Surg. 2014;38(1):233–240.

2. Chuenkongkaew T. Modification of split-thickness skin graft: cosmetic donor site and better recipient site. Ann Plast Surg. 2003;50(2):212–214.

Ostomy—Product Selection and Innovations



Margaret Hiler, MSN, RN, CWOCN, , Nursing Administration, Washington, DC, Dot Goodman, BSN, RN, CWOCN, , Georgetown University Hospital, Washington, DC, and Anne McArdle, MSN, ANP-BC, CWON, , Department of Surgery, Washington, DC

PROBLEM: Convex ostomy barriers help to solve pouching challenges and decrease leaking in areas of abdominal creases or folds and with retracted stomas. The increase in obesity and BMI in the US has likely contributed to the reported doubling of incidence of stomal retraction in recent decades. Until recently, there are few covnvex options available and ostomates continue to experience leaking. PAST MANAGEMENT: Convex barriers are often recommended with retracted stomas to help with protrusion. Convexity can also help keep peristomal skin flat within creases and folds. CURRENT APPROACH: Light or firm convexity may provide the right depth and curvature to provide a good seal; however, a more flexible convex barrier may be needed to conform to the abdominal contours, prevent the barrier from popping off, decrease pressure on peristomal tissue, and be more comfortable for the patient. PATIENT OUTCOMES: Three case studies demonstrate use of flexible, soft convex barrier to fill the gap in current options. #1: Transverse colostomy in deep abdominal crease. Frequent leaks with traditional convexity and was uncomfortable in belt. Soft convex 1-piece appliance appreciated 2–4-day wear time increased comfort without belt. #2: Flush, end-ileostomy; downward-pointing os within firm bowl. Leaking 1-2 times daily with traditional convexity 2 pieces. One-piece, precut, soft convex appliance increased to 3-day wear time and significant comfort. #3: Flush, end-colostomy in soft, obese abdomen. Five days wear time with traditional convexity. Deep, purple ring noted at appliance change. With soft convexity 1-piece, reports increase comfort and no pressure ring was visible on next appliance change. CONCLUSIONS: The soft convex barrier was found to provide an improved fit in many clinical applications. All patients found the barrier to be more comfortable. Further research would be indicated to determine in which clinical situations soft convexity would provide the best outcome.

Cottam J, Richards K, Hasted A, et al. Results of a nation-wide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Dis. 2007;9:834–838. http:((

Arumugam P, Bevan L, MacDonald L, et al. A prospective audit of stomas—Analysis of risk factors and complications and their management. Colorectal Dis. 2003;5(1):49–52.

Wound—Management of Complex Wounds



Margaret Simpson, RN, BSN, CWOCN, CFCN, CMSRN, , Surgery and Wound, St. Louis, MO

Over the past decade, negative pressure wound therapy (NPWT) has been used to promote a wound healing environment in complex wounds. NPWT has evolved to include instillation and dwell time (NPWTi-d). Previous porcine studies have shown that NPWTi-d with saline promotes granulation tissue formation1 and removes debris and infectious material.2,3 We present the use of NPWTi-d in 3 cases with complex wounds treated in an acute care setting. All cases were treated with 10-20 mL of 0.9% normal saline with a 10-minute dwell time followed by 3.5 hours of NPWT at −125 mmHg and systemic antibiotics. Dressing changes occurred 3 times per week. Case 1 was a 26-year-old female admitted for necrotizing soft tissue infection of the mons pubis and lower abdominal area. Comorbidities included obesity (BMI > 30 kg/m2), diabetes, and obstructive sleep apnea. Debridement and NPWT were initiated. NPWT failed due to body habitus. NPWTi-d was initiated and continued for 5 days. The patient was discharged 19 days after admission. Case 2, a 19-year-old male, was admitted for an infected right anterior thigh donor site following tongue reconstruction surgery. Comorbidities included congenital dyskeratosis, aplastic anemia, bone marrow transplant, bilateral lung transplant, hepatic fibrosis, squamous-cell carcinoma, and tongue resection. The patient had previously undergone several rounds of debridement and systemic antibiotics at an outside facility. NPWTi-d was initiated and continued for 3 days. The patient was discharged 4 days after admittance with intravenous antibiotics. Case 3 was a 57-year-old male admitted for a stage 4 pressure ulceration of the coccyx. Comorbidities included paraplegia, spinal infarction, diabetes, and colostomy. Sharp debridement was performed followed by NPWTi-d. The patient was discharged 20 days after admittance. All patients were discharged to long-term care facilities for follow-up. The patients reported no pain during the dressing changes and each wound showed improvement following adjunctive treatment with NPWTi-d.

Gupta S, Gabriel A, Lantis J, Teot L. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J. 2015:1–16. doi:10.1111/iwj.12452

Luca P. Diabetic foot wounds: the value of negative pressure wound therapy with instillation. Int Wound J. 2013:25–31. doi:10.1111/iwj.12174

Goss S, Schwartz J, Facchin F, Avdagic E, Gendics C, Lantis J II. Negative pressure wound therapy with instillation (NPWTi) better reduces post-debridement bioburden in chronically infected lower extremity wounds than NPWT alone. Am Coll Clin Wound Spec. 2014;4(4):74–80.

Ostomy—Stomal/Peristomal Complications



Mary Josephine Famorca, BSN, MAN, RN, WCC, COCN, , and Nancy Angulo, BSN, RN-BC, CWOCN, , Nursing, Phoenix, AZ; Debra Beauchaine, MN, A/GNP-BC, CWOCN-AP, , Cave Creek, AZ

INTRODUCTION: Calciphylaxis/calcific uraemic arteriolopathy, a rare poorly understood syndrome of small blood vessels, becoming blocked leading to black painful necrotic areas of skin. Mortality rate is 60%-80%. Patients affected have long standing history of chronic renal failure with other pertinent risk factors. Calciphylaxis lesion requires extensive and intensive wound management with medical interventions for patient to survive sequelae of sepsis. CASE: Middle-age male with extensive stage 4 pressure ulcer to his sacrococcygeal area requiring diverting colostomy to heal the wound. Diagnosis of chronic kidney disease with hemodialysis since 2007, diabetes mellitus and incomplete paraplegia is noted. Initial plan is to have diverting colostomy for eventual skin graft of his sacrococcygeal wound. Hospital stay was complicated by the development of peristomal calciphylaxis lesion (PCL) which made pouching challenges for staff. This required multiple pouching changes to keep peristoma clean. High acuity care needs of patient was aggravated by patient's noncompliance to diet restriction, pressure ulcer prevention efforts of staff and continued need for high doses of pain medication presented a challenge for health care team and safe discharge planning. DISCUSSION: Wound/ostomy team tried and evaluated various wound care products and different pouching techniques to increase wear time and help heal the PCL. Products like hydrogel, Hydrofiber Ag, gentian methylene violet, and enzymatic collagenase ointment were used based on the progress of the PCL. Staff education and interdisciplinary team effort in managing patient's medical and surgical issues assisted in dealing with the patient's case. CONCLUSION: PCL decrease in surface area affected and improved in appearance with use of various advance wound care product as patient's medical condition improved. Utilization of nursing process, intensive interdisciplinary collaboration have significantly managed complex PCL.

Tippet A. Calciphylaxis: What is and what it means for wound care.

Tiefenthaler M, Riedl-Huter C, Roth T, Bodner G, Mayer G. Ultrasonic diagnosis of calciphylactic lesions.

Giulio G, Beatirz T, Hans S. A calciphylactic dermatosis produced by histamine liberators.

Widespread cutaneous and systemic calcification (calciphylaxis) in patients with the acquired immunodeficiency syndrome and renal disease. J Am Acad Dermatol. April 1992;26(4):559–562.

Levin NW, Hoenich NA. Consequences of hyperphosphatemia and elevated levels of the calcium-phosphorous product in dialysis patients. Curr Opin Nephrol Hypertens. September 2001;10(5):563–568.

Bleyer AJ, Choi M, Igwemezie B, De la Torre E, White WL. A case control study of proximal calciphylaxis. Am J Kidney Dis. September 1998;32(3):376–383.

Howe SC, Murray JD, Reeves RT, Hemp JR, Carlisle JH. Calciphylaxis: Three case reports & review of literature. Ann Vasc Surg. July 2001;15(4):470–473.

Wound—Dermatological Management/Issues



Nancy Chaiken, RN, ANP-C, CWOCN, , wound care, Chicago, IL, and Elizabeth Miniscalco, RN, BSN, OCN, , Cancer Treatment Center, Chicago, IL

INTRODUCTION: Radiation therapy damages the DNA of cancerous cells to eradicate them. However, the skin may sustain damage as a result of radiation therapy that manifests as erythema, tenderness, and denudation, and these side effects can interrupt radiation therapy and negatively impact treatment progress. In severe cases, radiation therapy must be halted to allow the skin to heal. There are numerous guidelines for optimal skin care for patients undergoing radiation therapy that include the use of evidence-based product therapies for prophylaxis, but these are expensive. Typically, patients who are not covered by insurance at this facility cannot afford these more expensive products. In our radiation oncology unit, we observed frequent skin breakdown that necessitated additional skin management at week 4 of therapy despite the use of some affordable emollients and lotions. In 2012, a moisturizer with micronutrition was evaluated in a 6-week pilot study. The purpose of this study was to investigate the implementation of this affordable moisturizer with micronutrients as the standard of care for patients at risk of developing radiation dermatitis. METHODS: A retrospective X-month study was done for patients who met the inclusion criterion requiring that they be receiving radiation therapy. As part of their skin management, these patients were required to apply the study product 2 times a day during their radiation treatments. Skin health was monitored during the radiation therapy visits. The majority of these patients were breast cancer patients. RESULTS AND CONCLUSION: In the pilot study, there were no cases of erythema or skin breakdown over the 6 weeks we studied the patients. Similarly, this retrospective study has reinforced our decision to utilize the moisturizer with micronutrients as the standard of care a prophylactic for the skin health of patients at risk of developing radiation dermatitis. *Remedy Phytoplex® Nourishing Skin Cream, Medline Industries Inc.

Pinnix C, Perkins GH, Strom EA, et al. Topical hyaluronic acid vs standard of care for their prevention of radiation dermatitis after adjuvant radiotherapy for breast cancer: single-blind randomized phase 111 clinical trial. Int J Radiat Oncol. 2011;83(4):1089–1094.

Wickline MM. Prevention and treatment of acute radiation dermatitis: a literature review. Oncol Nurs Forum. 2004;31(2):237–247.

Wound—Evidence-Based Interventions



Julianne Rece, MSN, RN, CRRN, CWOCN, , and Naoko Otsuji-Miwa, RN, BSN, CRRN, CWOCN, CFCN, , Wound Care Department, Philadelphia, PA; Evelyn Phillips, MS, RDN, CDE, , Clinical Nutrition, Philadelphia, PA

PROBLEM STATEMENT: Many spinal cord injury (SCI) patients are transferred directly from ICUs to our acute rehabilitation hospital (AR). In 2014, 22% of patients overall and 41% of SCI patients were admitted with pressure ulcers (PrU). Many were ventilated, had poor nutrition, and had grossly necrotic unstageable coccyx/sacral PrUs at the time of admission. Once in AR, surgical options are limited or unsafe due to lack of insurance and/or medical condition, leaving only nonsurgical options available, which are too slow to be effective for AR patients. Failure to debride an unstageable coccyx/sacral PrU impedes therapy becomes a source of systemic inflammation and chronicity, and increases the likelihood of discharging the patient to a Skilled Nursing Facility instead of returning home. Larval debridement therapy (LDT) is a safe, nonsurgical, more effective means of wound debridement that does not require insurance approval. Although LDT is not recommended for debriding wounds in areas subject to pressure, AR patients are required to sit for therapy 3 hours/day, 5 days a week to meet AR criteria. CASE PRESENTATION: The case studies of 3 SCI patients with coccyx/sacral unstageable PrUs participating in 3 hours of therapy daily during LDT will be presented. Each patient had at least 1 application of LDT to their wound. PATIENT OUTCOMES: All 3 patients had significant levels of slough after 48 hours of LDT, though slough levels continued to decrease within the following few days after removal. Despite negative perceptions of LDT, these patients were receptive. CONCLUSION: Due to patient activity levels, we found occlusive dressings difficult to maintain which risked larval escape and/or a high level of larval mortality. We concluded that LDT was a viable option for the AR population with coccyx/sacral PrUs in need of rapid debridement.

Strohal R, Apelqvist J, Dissemond J, et al. EWMA document: debridement. J Wound Care. 2013;22(suppl 1):S1–S52.

Shi E, Shofler D. Maggot debridement therapy: a systematic review. Community Wound Care. December 2014.

Sherman AR, Wyle F, Vulpe M. Maggot therapy for treating pressure ulcers in spinal cord injury patients. J Spinal Cord Med. April 1995;18(2):71–74.

Felder MJ III, Hechenbleikner E, Jordan M, Jeng J. Increasing the options for management of large and complex chronic wounds with a scalable, closed-system dressing for maggot therapy. J Burn Care Res. 2012;33:e170–e176.

Gray D, Acton C, Chadwick P, Funnarola S, Leaper D, Morris C, Slang D, Vowden K, Vowden P, Young T. Consensus guidance for the use of debridement techniques in the UK. Wounds UK. 2011;7(1):77–84.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Pam Dobyns, RN, , Nursing, Colorado Springs, CO

ABSTRACT: People with mental illness have a need for foot care. This paper presents 3 case studies of foot care provided to patients in a psychiatric hospital. Ages ranged from 50 to 75 with diagnosis of depression, suicidal thoughts, dementia, and confusion. Comorbidities included diabetes and overwhelming fungal infection on feet and toenails. Two were males and one was female. In the past and present, foot care has usually been provided to residents of long-term care facilities, senior centers or in podiatrist offices. In general, mental health facilities do not provide this care. No formal foot care has ever been provided in this facility before; however, staff nurses providing overall care for patients do apply creams to feet when ordered by the physician. In this study, foot care began with trimming and cleaning of toenails and general inspection of feet. After a hard callous was found on a diabetic foot, more education was provided to patients to include inspecting feet daily, inspecting shoes and applying cream at night. All 3 patients were encouraged to see a podiatrist on a regular basis. While providing foot care, therapeutic interchanges occurred that allowed the nurse to provide emotional support as well. Patient's responses were usually immediate expressing relief of painful nails due to the cleaning and trimming process and feeling more steady on their feet. Callouses were found on the bottoms of the feet of both diabetics. Clinical implications include foot care can help establish a therapeutic relationship, help diabetics manage anxiety and help relieve foot pain improving mental health. It saves money by preventing diabetic foot ulcers and patient falls, both of which Medicare could deny payment for. Limitations include that some patients in mental health facilities are too psychotic and confused to allow foot care to be done.

Beattie AM, Campbell R, Vedhara K. “Whatever I do it's a lost cause.” The emotional and behavioral experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429–439. doi: 10.1111/j.1369-7625.2012.00768.x.

Burdette-Taylor M, Fong L. Foot and nail care. In: Doughty D, McNichol L, eds. Wound Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2016:530–557.

National Business Coalition on Health [NBCH]. Health care purchaser toolkit: Hospital-acquired condition payment policy. Published August 2009.

National Institute of Mental Health [NIMH]. (). Researchers call for coordinated care to address risks—NIH funded study. Published October 8, 2014.

Weil TP. Patient falls in hospitals: an increasing problem. Geriatr Nurs. 2015;36(4):1–6. doi: 10.1016/j.gerinurse.2015.07.004

Wound—Dermatological Management/Issues



Rachel Donovan, BSN, RN, CWOCN, CFCN, , Paula Schindler, BSN, RN, CWOCN, , and Janiece Weinberger, BSN, RN, CWS, , Wound Ostomy Department, Covington, LA

Toxic epidermal necrolysis (TEN) is an exfoliative disorder typically caused by a drug reaction. Clinically significant to Stevens Johnson syndrome (SJS) is dermoepidermal detachment. Mortality rate with these patients is upwards to 80%. A 77-year-old female was admitted to the critical care unit for sepsis, right foot cellulitis, urinary tract infection, and TEN. Comorbidities included hypertension, chronic kidney disease, right heel unstageable, and left heel stage II pressure ulcers. Cutaneous manifestations included full degloving of the hands and feet, large areas of epidermal dermal detachment, as well as mucous membrane involvement. Local wound therapy recommendations stressed immediate topical antimicrobials with a silver foam transfer dressing to reduce and prevent infection. Total body surface area (TBSA) affected was estimated to be 90%. The patient had the classic positive Nikolosky's sign in which the external layer of skin rubs off with slight friction or pressure. The WOC team was consulted for evaluation and recommendation for local wound care. Treatment methodology included use of a silicone foam dressing containing silver sulfate in combination with a superabsorbent dressing. In the selected therapy, the silver foam had a 30-minute activating rate with a sustained release of 14 days. The base layer of the dressing is a soft silicone which provided atraumatic application and removal. Furthermore, the silicone transfer silver dressing and the superabsorbent dressing effectively managed wound exudate while protecting from dermal exposure. Application of the described therapy allowed for epithelialization, moisture management, and pain management. Not only did the therapy facilitate accelerated epithelialization but also the patient received less dressing changes and better pain control with gentle healing. Lastly, implementing this local wound treatment plan resulted in 90% epithelialization on the dorsal and anterior aspects of both hands and feet. Despite multiple organ failure, integument healing occurred within 11 days.

Baranoski S, Ayello E. Wound Care Essentials. Amber, PA: Lippincott Williams & Wilkins; 2012:491–508.

Fagan S, Chai J, Spies M, Hollyoak M, Muller M, Goodwin C, Herndon D. Exfoliative diseases of the integument and soft tissue necrotizing infections. In: Herndon D, ed, Total Burn Care. China: Elsevier Inc; 2012:471–481.



Rachel Moseley, BSN, RN, CWCN, CWON, , and Cynthia Walker, MSN, RN, APRN-CNS, CWON, , Baltimore, MD

STATEMENT OF CLINICAL PROBLEM: Atypical skin lesion presentations among drug users present a growing health concern. Levamisole, a veterinary antiparasitic and cocaine adulterant agent, is detected in 70% of the drug. Levamisole intensifies mood enhancement and antidepressant effects (Hennings & Miller, 2013; Lawrence, Jiron, Lin, & Folbe, 2014). Levamisole was withdrawn as a cancer treatment in humans in 1999 (USA) and 2003 (Canada) due to side effects (Hou, Kronfli, Azzam, & Panju, 2015). Wound ostomy continence nurses (WOC) are commonly consulted for these atypical presentations. PATIENT PRESENTATION: Three identified patients, ages 42-53 years, presented to the hospital with large, well-demarcated purpuric/hemorrhagic plaques and rash on varied locations including legs and arms (3), ears and noses (2). Illicit drug use included heroin, cocaine, marijuana, and PCP. All 3 patients were tobacco smokers. Comorbidities included hepatitis C (3), rheumatoid arthritis (2), and anemia (2). A timely wound care nurse specialist consult was initiated by the medical team. Recommendations included imaging, toxicology screen, and dermatology consult. Pathology reports were suggestive of a diagnosis of cocaine/levamisole-induced cutaneous vasculitis (LIV). DESCRIPTION OF PAST MANAGEMENT: As a recently recognized cutaneous reaction, no standard of optimal care has been supported in wound literature for LIV at this time. CURRENT APPROACH: Surgical interventions with adjunctive topical management were implemented per WOC recommendations. In all 3 cases, the extensive escharotic wounds evolved over the next months. PATIENT OUTCOMES: All three identified patients required extensive surgical debridement, 2 required NPWT with skin grafts and one patient required a below the knee amputation. Known time to heal for these patients ranged from 3 to 8 months. CONCLUSIONS: Limited supporting evidence is available regarding optimal LIV management. The WOC nurse's role in early identification of levamisole's toxic effects is paramount to tissue viability, skin/wound care management, and community-related drug awareness interventions.

Lawrence LA, Jiron JL, Lin HS, Folbe AJ. Levamisole-adulterated cocaine induced skin necrosis of nose, ears, and extremities: case report. J Allergy Rhinol. 2014;5(3):e132–e136.

Hennings C, Miller J. Illicit drugs: what dermatologists need to know? J Am Acad Dermatol. 2013;69(1):135–142.

Hou C, Kronfli N, Azzam K, Panju M.). Breaking-out bad: a case of levamisole-induced vasculitis. Can J Gen Intern Med. 2015;10(2):50–52.

Wound—Management of Complex Wounds



Rene Amaya, MD, CWSP, , Houston, TX

Premature infants frequently experience skin complications as a result of underlying skin immaturity and trauma related to medical devices. Fully developed skin functions as a barrier against infection and caustic elements, but in premature infants, their immature epidermis inhibits the skin's ability to prevent infection, maintain water and electrolyte balance, and protect against absorption of toxic substances. Their fragile skin is furthermore susceptible to pressure and caustic elements in a neonatal intensive care unit environment. Skin tears and partial thickness wounds are a common occurrence in this population. Medical devices such as gastrostomy and tracheostomy tubes are often complicated by adjacent skin damage. A breathable skin protectant is needed to support the skin's natural barrier function and allow for amelioration of the damaged skin underneath. The purpose of this study was to evaluate the use of a cyanoacrylate no-sting liquid skin protectant as a method to protect skin and promote healing in premature neonates. In this 7 case series, 4 premature neonatal cases and 3 premature infant cases are presented. The patients' conditions include diaper dermatitis, a pressure ulcer, gastrostomy tube skin breakdown, tracheostomy tube skin breakdown, transperitoneal penrose drain skin breakdown, and abdominal wall skin breakdown. The cyanoacrylate no-sting liquid skin protectant was applied to the damaged skin and reapplied every 2 to 3 days as per facility standard of care. Skin was monitored for signs of complications. The time to resolution of skin breakdown was tracked. Within a few applications, the damaged skin was resolved in every case and no additional wound care intervention was required. In our use, we did not see any adverse events and this cyanoacrylate no-sting liquid skin protectant is now standard item in numerous hospital formularies. Photos will be presented.

Shwayder T, Akland T. Neonatal skin barrier: structure, function, and disorders. Dermatol Ther. 2005;18:87–103.

Chakravarthy D, Roman M, Kushner K. In-vitro evaluation of moisture vapor transmission rate of cyanoacrylate skin protection. Paper presented at Wounds UK and APWCA; Harrogate, UK and Philadelphia, PA; November 2014 and March 2015.

Neiswender L. Cyanoacrylates in neonatal and infant peristomal skin damage. Paper presented at SAWC; April 2011; Dallas, TX.



Rene Amaya, MD, , Houston, TX

OBJECTIVES: To demonstrate the effectiveness of ALH to safely aid in autolytic debridement and wound bed preparation followed by DAMA application to facilitate the healing progress of extravasation wounds in the neonatal population. METHODS: ALH has been used in wound care since antiquity and amniotic tissue was first noted to be used in burn care in the early 1900s at John's Hopkins Hospital. Wounds acquired in the hospital, such as IV associated wounds, are of particular concern to parents and caregivers. First prevention, then expedited healing, scar minimization, and earliest possible discharge to home are the optimal goals. We have 4 cases to present with this duel treatment of ALH to prepare the wound bed, and DAMA to promote rapid healing with minimal scarring. CASE 1: 32 week neonate—IV extravasation wound to R hand 1.5 × 1.4 × UTD (undetermined depth) due to slough. Use of ALH and DAMA resulted in complete closure in 27 days. CASE 2: 24 weeks' gestation, 12 weeks old—R foot extravasation 3.5 × 2.5 × UTD. Using duel treatments, wound closed in 34 days. CASE 3: 25 weeks' gestation, 4 weeks old—L hand extravasation 2 × 1.5 × UTD. Using dual treatments, wound closed in 21 days. CASE 4: 28 weeks' gestation, 4 weeks old—R ankle extravasation 3 × 4.5 × UTD. Using dual therapy wound closed on 8/9/15 after 41 days.

RESULTS: All four cases demonstrated desired debridement and expedited healing. Photos will be presented. CONCLUSION: ALH provided safe, effective debridement and pH modulation of the wound bed providing what may be an optimal wound bed for DAMA application. DAMA expedited wound closure for this sensitive group of neonates with only 2 applications usually required. No untoward effects were noted with this unique and successful protocol.

Wound—Product Selection and Innovations



Rose Raizman, RN-EC, MSc, MNurs, CETN(C), , Toronto, ON, Canada

OBJECTIVE: We evaluated cases of NPWTi-d alone or NPWT with C/ORC or C/ORC/silver dressings to successfully close complex wounds of different etiologies. METHODS: Ten patients with wounds of different etiologies (age range 40-90 years old) were evaluated in this case series. Patients were treated with either NPWTi-d or NPWT with C/ORC or C/ORC/silver dressings. NPWTi-d was initiated using a reticulated open cell foam (ROCF-V**). NPWTi-d protocol (depending on wound location) consisted of sodium hypochlorite (1:20 to 1:80) that was instilled until the foam was filled, followed by a 3–10-minute dwell time and 2-12 hours of continuous negative pressure therapy at −125 mmHg. Ten patients with wounds of different etiologies (age range 40-90 years old) were evaluated in this case series. RESULTS: All wounds were closed between Day 14 and Day 90. Patients reported decreased pain with each subsequent dressing change. Reduced visits for debridement in the operating room (OR) and reduced time to the split tissue skin graft (STSG) application were reported in applicable cases. In most cases, wound size reduced by 50% within 2 weeks of therapy start. When C/ORC/silver dressing was added to NPWT, there were no subsequent signs or symptoms of local infection in any of the presented cases, and time to closure in these patients seemed to be expedited. CONCLUSIONS: The presented case series suggest that NPWTi-d or NPWT with C/ORC or C/ORC/silver dressings is attractive for inpatient adjunctive treatment of acutely infected wounds. When wounds were debrided, early initiation of C/ORC/silver dressing in combination with NPWT improved healing rates and decreased local infection rates. The limitation of this case series is the lack of case controls to compare debridement times, healing times, and infection rates. Thus, comparisons were made to the general practice of the observers.

1. Sen CK, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–771.

2. Driver VR, et al. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg. 2010;52:17S–22S.

3. Venturi ML, et al. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) device: a review. Am J Clin Dermatol. 2005;6(3):185–194.

4. Kim PJ, et al. The impact of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133(3) 709–716.

5. Gottrup F, et al. Randomized controlled trial on collagen/oxidized regenerated cellulose/silver treatment. Wound Repair Regen. 2013;21(2):216–222.

Wound—Product Selection and Innovations



Sandra Burke, BSN RN CWCN, , Advanced Wound Healing Clinic, Rochester, MN

STATEMENT OF CLINICAL PROBLEM: Wound hygiene is defined as the process of cleansing the wound and surrounding skin to remove bacteria, residual dressings, inorganic material, or unhealthy or devitalized tissue. The process should be performed at each dressing change or wound assessment. In the clinical setting, wound hygiene is often not performed, or is done insufficiently and ineffectively, leading to persistent inflammation, infection, and delayed wound healing. PAST MANAGEMENT: Despite the availability of wound cleansers and surfactants, most of our providers use moistened saline soaked gauze to perform wound hygiene resulting in often-aborted painful, time-consuming procedures often necessitating 20-minute delays to apply topical analgesics. CURRENT CLINICAL APPROACH: Our wound clinic evaluated a monofilament debridement mitt (MDM) designed to augment wound hygiene. MDMs were saturated with normal saline, a hypochlorous acid solution, or a preservative-free polymer cleanser and applied in a circular motion for 3 to 5 minutes to lower-extremity hyperkeratotic skin associated with venous hypertension or lymphedema, “road rash” abrasions and wounds with loose nonadherent slough. MDM application pressure was increased per patient tolerance to achieve adequate wound hygiene. RESULTS: Over 25 patients have received MDM wound hygiene. Clinicians report easier removal of inorganic material, residual dressings, devitalized tissue, fewer or less extensive debridement procedures, more effective wound cleansing, cleaner periwound skin, and faster procedure times. Patients reported wound hygiene with MDM as comfortable and were impressed with skin or wound appearance. CONCLUSIONS: A wound hygiene protocol that incorporates MDM had been adopted by our wound clinic and is in the process of being adopted in other areas of the hospital, including the emergency department, medical-surgical units, and for lymphedema rehabilitation patients.

1. Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J. December 2012;9(suppl 2):1–19.

2. Sakarya S, Gunay N, Karakulak M, Ozturk B, Ertugrul B. Hypochlorous acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds. 2014;26(12): 342–350.

Wound—Dermatological Management/Issues



Sandra Oehlke, APRN, CNP, CWOCN, DNC, DCNP, CCRP, CCM, , Skin Integrity, Minneapolis, MN

STATEMENT OF CLINICAL PROBLEM: Care of a Caucasian infant, and 2 African American school-aged males with an atopic dermatitis flares. Infant presented atopic dermatitis and secondary impetiginization, second child presented with eczema coxsackieum, and the third with eczema herpeticum. The pruritis caused the patients to excoriate their skin, eroded vesicles and bullae created from the viral conditions required wound care as well. • A skin culture determined the etiology of the infection. • Antibiotics and antivirals are prescribed. • Pruritis was managed with deep dermal hydration through soaks and wraps. • Transepidermal water loss was managed with topical ceramide creams and bland ointments. • The flare was treated with topical steroids appropriate to the level of the flare. • Wound care with petrolatum gauze, and medical grade honey was used on excoriations and erosions. • Education was provided to the family to manage atopic dermatitis. Etiology of atopic dermatitis, i.e. filaggrin deficiency, ceramide deficiency was discussed. DESCRIPTION OF PAST MANAGEMENT: Oral steroids have been used in the past to manage atopic dermatitis flares but are no longer used to manage flares. They are contraindicated for patients with eczema herpeticum. CURRENT CLINICAL APPROACH: Antibiotics, antivirals, and topical treatments with steroids, moisturizers, and wound care were effective. PATIENT OUTCOMES: Relief from pruritis was immediate with the application of wet wraps. Increased patient comfort and ability to sleep was seen in one day. Decreased erythema and granulation of open areas was noted in 3 days. Parents reported the patients looked better and slept better. Parents articulated how to do treatments at home. CONCLUSIONS: Collaboration with hospitalist and dermatology-prepared CWOCN APRN can diagnose and treat patients with atopic dermatitis who require dermatological and wound care treatments. Accessed November 4, 2105. Accessed November 4, 2105. Accessed November 4, 2105. Accessed November 4, 2105. accessed November 4, 2105.

Wound—Management of Complex Wounds



Stéphanie Laferriere, , Programme soins chirurgicaux, Sherbrooke, QC

La gangrène de Fournier est une infection rare impliquant les tissus mous de la région périnéale. La synergie des bactéries provoque des thrombus des vaisseaux du tissus sous-cutanée causant la nécrose de la peau. La prise en charge débute par un débridement agressif de ces tissus, ainsi que l'utilisation d'antibiotique approprié. Dans un deuxième temps, la thérapie par pression négative (TPPN) est une pratique courante. BUT: Évaluer la possibilité d'utiliser la TPPN dans la région vaginale et périnéale afin de combler la perte de substance, tout en conservant l'intégrité de l'ouverture vaginale et sa fonctionnalité. MÉTHODE: Cas unique d'une femme primipare ayant eu une gangrène de Fournier affectant la région anale, périnéale et génitale à la suite d'un accouchement naturel causant initialement une déchirure du 3e degré. Suite au débridement agressif de la nécrose, la création d'une dérivation fécale a été effectuée dans le contexte d'une atteinte du sphincter anal. La TPPN a été installée avec une éponge en polyuréthane éther à 125 mmHg en continu dans la cavité vaginale et périnéale. Une évaluation de l'évolution a été notée aux jours: 1, 3,5 et 8 par une personne dédiée et par la prise de photographies à tous les changements de pansement de la TPPN. RÉSULTATS: La TPPN a été utilisée pour une durée totale de 8 jours permettant une récupération complète de la perte de substance du vagin et de la région périnéale, soit environ 2 cm d'épaisseur. L'entrée vaginale et sa fonction ont été préservées. CONCLUSION: L'utilisation de la TPPN dans la région vaginale a permis une récupération complète de la perte tissulaire, une amélioration du confort de la patiente, une réduction de la fréquence de changement de pansement et une diminution des heures/soins. Il est également possible de penser que la TPPN a également permis d'éviter une vaginoplastie ou une chirurgie reconstructive.

Basoglu M., et al. (2006). Management of Fournier's Gangrene: Review of 45 cases. Surgery Today. P. 558–563.

Carvalho J.P. (2007). Relation between the Area Affected by Fournier's Gangrene and the Type of Reconstructive Surgery Used. A study with 80 patients. Clinical Urology. P. 510–533.

Sihan R., et al. (2015). Fournier's Gangrene in Pregnancy. Obstetrics & Gynecology. Vol 125 n. 6. P. 1342–1344.

Ozkan O.F, et al. (2014). Fournier's Gangrene Current Approaches. International Wound Journal. P. 1–4.

Wound—Product Selection and Innovations



Suzanne Koerner, BSN, RN, CWOCN, , Mount Carmel West, Columbus, OH, and Diane Adams, BSN, RN, CWCN, , Columbus, OH

PROBLEM: Patients present with lower extremity venous insufficiency and ulcerations complicated by surrounding edema and thick viscous exudate. Initially, compression wraps were used to control the edema; however, no advanced wound care dressings prevented the thick exudate from macerating the parawound skin. Will new technology of soft silicone foam with Unique Exudate Channels* (UEC) assist with the transference of thick viscous exudate away from the skin, thereby allowing venous leg ulcers to heal? METHODS: Four patients were selected to use this new technology. Three of the 4 patients were seen in an outpatient Resident Clinic. The fourth patient was seen in a Homecare setting. All patients had venous insufficiency with ulcerations and thick viscous exudate. The lower extremities were cleansed with mild soap and water. Honey Calcium Alginate was applied to one ulceration with depth greater than 0.5 cm. Foam dressing with UEC* was placed over the ulcerated skin with compression wraps consisting of zinc-impregnated gauze, roll gauze and short stretch self-adhering bandage roll applied from toes to knee. Patients were seen 1-2 times per week for dressing changes. RESULTS: All 4 patients benefitted from the use of this new technology. Each patient had troublesome viscous drainage managed by the use of the new foam dressing technology with UEC* allowing the periwound skin to remain intact. Two morbidly obese patients with 3+ edema used the dressings for 3 weeks at which time they were placed back into traditional compression wraps due to diminished, thin exudate. It was noted that the thick viscous drainage was effectively transferred to the outer dressings and all the patients continue to heal with a decrease in ulceration size.

Bryant RA. Acute & Chronic Wounds. St. Louis, MO: Mosby; 2000.

Cutting K. Honey & contemporary wound care: an overview. Ostomy/Wound Manage. 2007;53(11):49–54.

Davis J, Gray M. Is the Unna's boot bandage as effective as a four-layer wrap for managing venous leg ulcers. J Wound Ostomy Continence Nurs. 2005;32(3):152–156.

Wound—Management of Complex Wounds



Vita Boyar, MD, , Pediatrics, New Hyde Park, NY

A common cause of delayed wound healing/wound dehiscence is colonization with microbes, often leading to infection. Infection can impede the healing process by inducing a strong systemic and local inflammatory response. Critically ill pediatric patients can develop severe illness in response to bacterial endotoxins, systemic inflammatory reaction, or antibiotics themselves. Side effects and potential resistance to antibiotics are a real problem in pediatric population; furthermore, the effect could be suboptimal due to biofilm formation and poor penetration by antibiotics. Many “adult” products are contraindicated in neonates due to its side effects. Pediatric population is in great need of less harmful treatment. Studies support the use of nonmedicated dressings in managing wound bioburden. A new concept, hydrophobic interaction, employs fatty acid dialkylcarbamoylchloride (DACC) coated dressing fibers and their ability to interact with the surface microbes. Microbes, including fungi, are irreversibly bound through the physical mechanism of hydrophobic interaction to DACC coating on the dressing surface. They are removed painlessly during dressing change. The risk of bacterial resistance or sensitization is avoided. Damaging endotoxin release in the wound bed is prevented as well. We present case series involving neonatal and pediatric patients with delayed wound healing that responded well to dialkylcarbamoylchloride (DACC)-coated dressing. We include a newborn with congenital diaphragmatic hernia that developed unstageable pressure ulcers while receiving life-saving ECMO (extracorporeal membrane oxygenation), a 10-year-old female with Stage 4 vertebral PU from immobility, infected with Pseudomonas aeruginosa and a 2-week-old neonate with dehisced thoracic wound after hypoplastic left heart repair. The wounds were treated with DACC coated dressing in combination with secondary dressing or NPWT device. Dressings were changed according to wound characteristics. Wounds closed successfully. DACC-coated dressing represents a unique “bacteria-removing” option without systemic antibiotics/inflammatory response, 2 factors paramount to avoid in described population.

1. McGuire J, Cutting K. In vitro and clinical experience of Cutimed Sorbact: the evidence base. J Wound Care. May 2015;24(5):s3–s28.

2. Wolcott R, Rhoads D, Dowd S. Biofilms and chronic wound inflammation. J Wound Care. 2008;17(8):333–341.



Connie Schulz, RN, BN, CETN(C), , Wound/Ostomy team, Ottawa, ON, Canada, and Vicki Meyouhas, RN, MScN, ET, , Wound and Ostomy Team, Ottawa, ON, Canada

Acquired hemophilia, a rare autoimmune condition in which the body forms antibodies that attack clotting factors, can have significant implications for wound care as bleeding is a serious concern. In this case study, we present the courses of treatment for 3 individuals who required wound care in the context of their acquired hemophilia. The wounds in these case reports were either a direct result of their acquired hemophilia or unrelated to it but complicated by it. The first patient developed a significant hematoma after trauma to the leg, the second required fasciotomies due to other medical issues, and the third developed a stage 4 sacral-coccygeal pressure ulcer during a prolonged admission. All 3 patients required negative pressure wound therapy (NPWT) as part of their wound care regimen. There are no case reports in the literature regarding the safe use of NPWT in the acquired hemophilia host. This management was selected after careful considerations of potential bleeding and further injury and an exhaustive assessment of the host. Pertinent specialists were consulted at all stages of wound care interventions. All 3 patients responded very well to NPWT. Their wounds decreased in size, and granulation tissue covered the majority of the wound base. Bleeding was minimized with the use of a wound interface, along with lower than usual suction (−75 mm Hg). Additionally, bleeding was managed with the use of anti-inhibitor coagulant complex and tranexamic acid, along with careful and ongoing monitoring of the patients.

Wound—Evidence-Based Interventions



Myungshin Kim, , Nursing, Seoul, South Korea

Removing barriers timely and proper intervention can be a key to successful wound healing. In normal wound healing process, wounds generally have interfered with various factors such as failure of pressure unloading, nutritional debilitation, bacteria burden, and hemodynamic instability. Bacterial burden leads to formation of biofilm. Once biofilm is built on wound beds, the healing process get stuck on inflammatory phase chronically. The most recommended method to reduce biofilm is mechanical removal including debridement and vigorous cleansing. However, accompanied pain with procedure is another issue for health care professionals. This poster contains 3 cases of chronic wounds managed by honey-based dressing. The first case was a fungating wound due to breast cancer. Main problem was severe pain during dressings as well as odor and exudate. Wet-gauze dressing with metronidazole powder was not helpful for all symptoms. After gentle saline irrigation, honey-impregnated alginate was applied with hydrofiber and fluffy gauze pad. Petrolatum-based barrier cream was applied on periwound. Within 2 weeks, we could observe autolysis of necrotic tissue, reducing of bioburden, low score of pain scale, control of foul odor, and epithelialization of wound edge. Second case was a pressure ulcer on sacrum. This Stage II pressure ulcer occurred after operation. Slim and shiny biofilm was observed on the wound bed. Honey-impregnated alginate and hydrofiber applied with gauze daily for 1 week. As reducing bioburden, autolysis of necrotic tissue and granulation appeared with epithelialization. Third case was a refractory pressure ulcer occurred 1 year ago. The patient was on condition of both foot amputations due to diabetes. Antibiotics and topical ointment were not effective. Honey-impregnated alginate with foam dressing was applied. In 2 weeks, clear wound bed appeared and the edge of wound was shown with proceeding of epithelialization.

Lee DS, Sinno S, Khachemoune A. Honey and wound healing: an overview. Am J Clin Dermatol. 2011;12(3):1–10.

Pieper B. Honey-based dressings and wound care: an option for care in the United States. J Wound Ostomy Continence Nurs. 2009;36(1):60–66.

Phillips PL, Wolcott RD, Fletcher J, Schultz GS. Biofilms made easy. Wounds Int. 2010;1(3):1–6

Swanson T. Innovations in the assessment and diagnosis of wound infection. Wounds Int. 2011;2(1).

Yusof N, Ainul Hafiza AH, Zohdi RM, A. Bakar MZ. Development of honey hydrogel dressing for enhanced wound healing. Radiat Phys Chem. 2007;76:1767–1770.





Aileen Ankrom, BSN, RN, CWOCN, , Cynthia Glenn Timms, BSN, RN, CWOCN, and Angela Dye, BSN, RN, CWOCN, , WOC Nursing Department, Atlanta, GA

Our facility identified a need to assure accurate classification of pressure and nonpressure ulcer wounds and accurate staging of pressure ulcers by Champion of Skin Integrity (CSI) nurses. Every bedded unit in our facility has a CSI, who acts as a resource nurse on their own unit/floor. One of the CSI's responsibilities is to participate in the quarterly NDNQI Prevalence Study. All RNs in our facility have an annual requirement to complete NDNQI modules 1 and 2, Pressure Ulcer Prevention video, and take the test on our Healthstream Learning Center. The WOC nurses sought to improve CSIs accuracy in wound classification and pressure ulcer staging by conducting Interrater Reliability testing of wound identification and pressure ulcer staging prior to each quarterly NDNQI survey for over 1 year. Each test was followed by discussion and clarification. The reliability test consisted of pictures of different stages of pressure ulcers, and nonpressure wounds such as venous and arterial ulcers, diabetic ulcers, moisture-associated dermatitis, and skin tears. After the test, each wound was discussed in terms of characteristics, types, and stage (for pressure ulcers). Baseline test results showed an average of 78.25% competency in April 2014. By July 2015, scores increased to an average of 86.02% competency. These data indicate that simple strategies can be effective in improving staff nurse accuracy in wound classification and pressure ulcer staging. However, we are working to further advance CSI proficiency in identification of pressure ulcers and other types of wounds through ongoing education and use of our online resources.

Berquist-Beringer S, Davidson J. NDNQI. Published 2015.

Wound—Management of Complex Wounds



Allyson Rigel, BSN, RN, CWOCN, CFCN, , Rebecca Rothemich, BSN, RN, CFCN, CWCN, , Phill Botham, BSN, RN, ET, CWON, , Julie Ross, BSN, RN, CWOCN, , and Emily Pellegrini, BSN, RN, CWOCN, , Wound Care, Charleston, SC; Glenda Brunette, MSN, RN, CWON, , Specialty Nursing, Charleston, SC

Head and neck cancers account for 3% of cancers in the United States and $3.6 billion in annual spending. At an academic magnet medical center in the Southeastern United States, scapular and latissimus free flaps are often used to reconstruct resected head and neck cancers. Current practice in managing these flap donor sites for our ENT oncology and WOC nursing teams is to apply negative pressure wound therapy (NPWT) to the flap donor site to prevent wound complications such as seroma, dehiscence, and surgical site infection. Within 72 hours of surgery, transparent film is fenestrated and applied over the flap harvest site and surrounding tissue. Open cell polyurethane foam is applied over the entire flap donor area to address the underlying defect with the intent of bolstering the tissue layers. After securing the foam with additional transparent film, negative pressure is applied continuously at 175 mmHg. The dressing is left in place with weekly changes until patient's discharge, or discontinued at physician's discretion. NPWT has been utilized since the 1980s on a routine basis to better manage both acute and chronic wounds. While numerous studies have been performed and found throughout the literature, little research exists on utilizing NPWT for the management of flap donor sites closed by primary intention. A retrospective review of 94 patients treated at our facility demonstrated a 12% rate of complication in patients not treated with NPWT versus 6% in patients treated with NPWT (Schmedes, Malin, Srinivas, & Skoner, 2012). This innovative methodology has yielded positive patient outcomes thus far, with no negative outcomes related to the NPWT. This novel protocol shows promise in promoting optimal patient outcomes as well as reducing expenses related to wound complications.

Schmedes G, Banks C, Malin B, Srinivas P, Skoner J. Massive flap donor sites and the role of negative pressure wound therapy. Facial Plast Reconstruct Surg. 2012;147(6):1049–1053. doi:10.1177/0194599812459015.

Ostomy—Psychosocial and Quality of Life Aspects



Angela Richardson, BSN, RN, CWOCN, , Advanced Clinical Practice, Durham, NC, and Lara Leininger, BSN, RN, CWOCN, , WOC Nurse Consult Service, Chapel Hill, NC

The WannaWearOne Ostomy AWEARness (WWO) 5k race promotes patient advocacy and raises ostomy awareness in the local community and nationwide. Established by 2 North Carolina WOC nurses, the race also serves to raise significant funds for the United Ostomy Associations of America (UOAA). The unfortunate negative stigma and lack of understanding surrounding ostomy surgeries and ostomates, people living with ostomies, inspired these advocating nurses to enlist the community's help in promoting positive ostomy awareness. The inaugural WWO 5k run occurred on October 4, 2014, in Durham, NC. It inspired sister events in Kingsport, TN, Portland, OR, and worldwide through a Virtual Race in 2015. The first race raised $15,000 for the UOAA, while the 2015 race exceeded $40,000 in funds benefiting the UOAA and ostomates across the country. The money raised helps to strengthen ostomy support groups nationwide, funds lobbying for ostomy-related actions, and pays for patient education literature and online campaigns. A portion of the proceeds helped fund the Sandi McBride CARES Scholarship, which sponsors a North Carolina ostomate's attendance to the biannual UOAA conference. In addition to raising money for the UOAA, the 5k events raised critical ostomy awareness, promoting networking and collaborative efforts between WOC nurses, doctors, advocacy groups, healthcare companies, patients, their families, and the community-at-large. Many local businesses donated time and funds to the cause while simultaneously learning about ostomy surgery. Event participants were provided an ostomy pouch and were encouraged to read enclosed educational material to further awareness and understanding. Additional efforts, via a web site and Facebook page, reached thousands of people worldwide that were unable to attend the live event. The WWO 5k will be held annually on Ostomy Awareness Day and will commit to advocacy for ostomates by promoting positive acceptance and assisting in the realization that ostomy surgery saves lives!

Ostomy—Clinical Outcomes



Anne Van Der Drift, , ET nurse, General Surgery, Paris, and Aude Michaud, , Boulogne Billancourt

INTRODUCTION: Year after year, the choice of the most appropriate device is becoming more complicated for the patients and ET nurses due to a large number of appliances available on the market. A new coupling system has recently been developed and proposed to patients. An international survey has been carried out in Europe in order to validate the user satisfaction of this concept. AIM: Evaluation of a new 2-piece mechanical coupling and guiding system by patients and ET nurses on comfort, ease of use, and security. METHOD: A large survey has been proposed to ET nurses in 8 European countries. Colostomates, ileostomates, and urostomates who were already wearing this new appliance were eligible for inclusion. An evaluation form had to be completed by each patient and a final appreciation of the appliance had to be given by both patients and ET nurses. RESULTS: A total of 1155 patients were included by 307 ET nurses in France, Spain, Germany, Italy, Belgium, Denmark, Switzerland, and Finland between 04/2013 and 05/2014. The large majority of patients had digestive stoma with 45% of ileostomates, 39% of colostomates, and 16% had urostomy. 74% of the participants were newly operated with no experience of device and 26% were already wearing a pouch. All results will be presented in detail. The guiding system offering 3 possible pouch positions was rated “Very easy or easy” to use by 91% of the participants. The comfort and the security feeling were also rated as “very satisfying or satisfying” by 88% and 86% of patients, respectively. More than 2/3 of patients decided to continue to use this new device. CONCLUSION: This patient survey demonstrates the real benefits of this new device for the patients. The mechanical coupling system with an innovative guiding system goes along with high flexibility, comfort, and security.

Ostomy—Evidence-Based Interventions



Armi Earlam, DNP, MPA, BSN, RN, CWOCN, , and Lisa Woods, MSN, RN-BC, CWOCN, , Wound, Ostomy and Continence Department, Wheat Ridge, CO; Sharon Lundy, RN, BSN, OCN, , Oncology, Wheat Ridge, CO

Our acute care facility's gastrointestinal (GI) diseases site team's mission is to achieve the most current care for our patients with GI-related cancer. The team meets 6 times a year. The participants in this meeting include the GI physicians, surgeons, radiologists, oncologists, our genetic counselor, our lead wound, ostomy, and continence (WOC) nurse, cancer navigators, and selected managers and nurses. Its objectives are to (1) improve communication, information, and education with primary care physicians (PCP); (2) educate patients and physicians about colorectal cancer screening and treatment; (3) streamline processes to offer timely and superior GI cancer care while adhering to evidence-based protocols in GI cancer workup and treatment; (4) incorporate genetic counseling into the colorectal cancer program; (5) develop a survivorship program; (6) offering supportive services for GI patients; (7) update the team regarding the drug trials conducted in our facility; and (8) participate in our facility's marketing efforts. From 2010 to the present year, the team has successfully reached many important goals: disseminating information to the team regarding the ostomy care process in the facility (preoperative marking, ostomy education, ostomy support group, discharge planning); highlighting the three staff WOC nurses' roles; providing free colon cancer screening to the community; supporting the facility's marketing endeavors; completing a pancreatic cancer screening algorithm; fostering interdisciplinary collaboration in our facility; and enhancing our relationship with our community partners such as the PCPs and home health agencies.



Armi Earlam, DNP, MPA, BSN, RN, CWOCN, , School of Nursing, Denver, CO

This 2015 Doctorate of Nursing Practice (DNP) project used a quasi-experimental, pretest posttest design. This was conducted in a metropolitan area in one of the Rocky Mountain states. PURPOSE: The purpose of this quality improvement project is to improve the home health nurses' knowledge regarding peristomal skin care through an in-service education provided by a wound, ostomy and continence nurse (WOCN). GOAL: The goal is to improve the nurses' knowledge on peristomal skin care, with the ultimate goal of positively impacting the care of the ostomy patients at home. Knowledge improvement was evaluated by administering an identical pre- and posttest on peristomal skin care. The 10-item test was written by Debra Netsch, DNP, RN, APRN, CNP, CWOCN, and Bonnie Sue Rolstad, MS, RN, CWOCN. This test is part of a continuing education class available through webWOC and had previously been administered to nurses. OBJECTIVES: (1) Provide a 1-hour, evidence-based in-service to increase the home health nurses' knowledge on peristomal skin care. (2) Administer a pretest to demonstrate baseline knowledge of participant nurses regarding peristomal skin care. (3) Administer a posttest to demonstrate knowledge acquisition. METHODS: The author's university's internal review board approved the study. The author developed an in-service and a blog discussing the topic. The author went to the different home health agencies to conduct the hour-long in-service. Demographic forms were completed by the participants. A test was administered before and after the in-services. Descriptive and inferential statistics were used to analyze the data gathered. RESULTS: Eighty-six home health nurses from a convenience sample participated in this project. A statistically significant improvement in mean knowledge scores was noted in the postintervention assessment, suggesting that educational intervention was successful in increasing nurses' knowledge on the topic. There was a significant difference in the pre- and posttest scores, pretest (M = 0.5267, SD = 0.19062) and posttest (M = 0.7791, SD = 0.16458); t(85) = −9.521 p < .001. CI = −0.30502 to −0.19963.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Ave M. Preston, MSN, RN, CWOCN, ACNS-BC, , Surgical Nursing, Philadelphia, PA

BACKGROUND: An academic medical center encouraged clinical nurses to obtain wound care certification by hosting a 4-day educational program offered by the Wound Care Educational Institute. Twenty nurses attended the course and passed the national certification exam. The didactic learning experience and certification alone, however, did not adequately prepare these clinical nurses to be a local resource on their unit. The wound, ostomy continence (WOC) nurse developed a creative method for knowledge translation and sought budget approval for a position to support a mentored “Wound Care Fellowship.” PURPOSE: In phase 1 of the fellowship, wound care fellows spend 4 consecutive Wednesdays with the WOC nurse performing wound rounds and 1 day observing in the outpatient wound care clinic. The WOC nurse provides one-to-one mentoring focusing on assessing wounds, accurately staging pressure ulcers, developing plans of care, and educating patients and clinical nurses on pressure ulcer prevention and wound management. A completed wound care consult includes an uploaded photo and automatically populates an order set that the provider submits after interprofessional collaboration. After completion of phase 1 of the fellowship, the wound care fellow delivers a scholarly presentation of case studies and lessons learned at a monthly Skin Care Champion meeting. OUTCOMES: The second phase of the fellowship pairs 2 wound care fellow “graduates” who round with greater independence but with oversight of the WOC nurse mentor as needed. Post fellowship data demonstrates that when wound care fellows evaluate patients, there was increased accuracy of wound type and pressure ulcer staging, increased implementation of evidence-based prevention strategies, enhanced documentation with inclusion of wound photography, activation of wound care order set, and reduction in variation of practice. A wound care fellowship experience mentored by a WOC nurse provides an innovative, valuable, and highly satisfying educational opportunity that positively impacts patient outcomes.

Ostomy—Clinical Outcomes



Bonnie Alvey, ACNS-BC, APRN, CWON, , Wound and Ostomy Outpatient Clinic, New Orleans, LA

Patients undergoing surgery resulting in a temporary or permanent ileostomy are at higher risk for readmission due to dehydration. In today's climate of accountable care and pay for performance, all stakeholders are diligently working to reduce readmission rates. Dehydration may be one of the more preventable complications that result in readmission. Patients with a new ileostomy experience extra challenges. With today's shorter length of stay, there is less time for teaching and counseling by the wound, ostomy and continence (WOC) nurse. Discharge preparation includes all aspects of ostomy care with emphasis on dehydration prevention. OBJECTIVE: The WOC nurse and team at a 600-bed teaching hospital collaborated on a quality improvement project to reduce ileostomy patient readmissions due to dehydration. Changes to practice include a new written tool-simplifying intake and output data collection postdischarge and phone follow-up. Specific output guidelines are explained and included in written discharge materials. Within 48 hours of discharge, the outpatient WOC nurse or other team member makes follow-up calls to the patients and documents findings. ASSESSMENT: Patient's compliance to measuring their output varies. Patients report they forget the measuring container and therefore might only record the number of times emptying. If the nurse feels the patient is experiencing signs of impending dehydration, additional instructions are given and closer surveillance is initiated. Dehydration prevention also depends on successful pouching because patients experiencing frequent leakages eat and drink less in an effort to stop pouch leakages. The follow-up call includes a query about pouching and any other concerns. For the patient having leakage problems, an outpatient visit with the WOC nurse within 24 hours is offered or phone guidance if a visit is not feasible. OUTCOME: This initiative implemented in September 2014 has resulted in a decrease in readmissions due to dehydration.

Goldberg M. Management of the patient with a fecal ostomy; best practice guidelines for clinicians. J Wound Ostomy Continence Nurse. 2010:596–598.

Nagle DP. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55(12):1266–1272.

Wound—Evidence-Based Interventions



Carole Bauer, MSN, RN, ANP-BC, OCN, CWOCN, , Chronic Disease Management, Troy, MI, Morris Magnan, PhD, RN, , Ambularoty Care, Detroit, MI, and Pamela Laszewski, BSN, RN, OCN, , Radiation Oncology Center, Detroit, MI

PURPOSE: Self-care to prevent radiation dermatitis is imperative. However, patient adherence to recommended skin care is not always optimal. Poor adherence to skin care occurs when patients receive instruction that is poorly organized, inconsistent, not evidence-based, and contrary to their learning style. This quality improvement project sought to optimize adherence to skin-care recommendations and decrease skin toxicity among radiation oncology (RT) patients being treated for head and neck cancer. OBJECTIVE: To promote adherence to skin care and minimize skin toxicity among RT head and neck patients by ensuring that

  1. skin-care recommendations are evidence-based and in accord with ONS PEP guidelines.
  2. skin-care education and reinforcement information are standardized and delivered consistently by nurse educators.
  3. multimedia instructional materials are theoretically structured to meet the patient's preferred learning style.

OUTCOMES: Adherence to the skin-care protocol was moderate during week 1 but thereafter 96% or more of the patients used both products at least once a day. Satisfaction with initial teaching was high. On a 4-point scale (1 = not satisfied; 4 = very satisfied), the average level of satisfaction was 3.79 with a narrow standard deviation (SD = 0.41). Time to onset of a skin reaction (Grade 1 or greater) was evaluated in consecutive days from the first day of treatment. For the new protocol group, the average time to onset was 20.84 days (SD = 12.59) whereas time to onset for the old protocol group was 17.15 days (SD = 11.42). There was a nearly 4 day delay in onset in the new protocol group. The mean level of skin toxicity for the experimental group was 1.91 whereas the mean level of skin toxicity for the control group was 1.98. Using independent samples t test, there was no statistically significant difference (t109 = −0.33, p = .739) in the average severity of skin toxicity between groups.

Feight D, Baney T, Bruce S, McQuestion M. Putting evidence into practice: evidence-based interventions for radiation dermatitis. Clin J Oncol Nurs. 2011;15(5):481–492.

Radiodermatitis. Oncology Nursing Society Putting Evidence into Practice Website. Published July 29, 2015. Accessed October 14, 2015.

Bauer C, Laszewski P, Magnan M. Promoting adherence to skin care practices among patients receiving radiation therapy. Clin J Oncol Nurs. 2015;19(2):196–203. DOI: 10.1188/15.CJON.196-203

Continence—Issues in Bladder and Bowel Continence Management



Carolyn A. Sorensen, MSN, RN, CRRN, CWOCN, , Nursing Education, Washington, DC

There are approximately 250,000 Americans currently living with spinal cord injury (SCI) and an estimated 11,000 new injuries occur annually. Damage to nerve pathways following SCI can result in sensory and/or motor dysfunction leading to 2 very different types of bowel dysfunction. Reflex, or upper motor neuron bowel, or areflexic, or lower motor neuron bowel dysfunction. GI changes following SCI include increased colorectal transit time, loss of colonic compliance, and changes in sphincter tone and pelvic floor musculature. This often leads to symptoms of constipation, fecal incontinence, and autonomic dysreflexia. Uncontrolled bowel evacuation is the most common complaint and is the greatest source of social discomfort. Bowel dysfunction has been reported to affect life activities in up to 61% of people with SCI. This suggests a need to incorporate quality of life into the development of interventions and as a program outcome. Therefore, the interdisciplinary team must work with the spinal cord–injured patient to establish a bowel program that achieves continence or containment, and that supports community reintegration. The WOC nurse with an understanding of continence issues can be an essential part of this team. This poster will review the essential components of a bowel program including: Anatomy; Process of defecation; Effect of SCI on bowel function; Description and goals of a bowel program; Safe and effective use of medications; The role of therapy with adaptive equipment related to expected level of function; Prevention and treatment of common bowel problems; When and how to make medication or schedule changes; Management of emergencies; Long-term implications of neurogenic bowel dysfunction.

1. Nelson A, Zejdlik C, Love L eds. Nursing Practice Related to Spinal Cord Injury and Disorders: A Core Curriculum. EPVA, 2001.

2. Doughty DB. Urinary and Fecal Incontinence, Current Management Concepts. 3rd ed. Mosby; 2006.

3. Consortium for Spinal Cord Medicine. Neurogenic Bowel Management in Adults With Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Providers. Paralyzed Veterans of America; March 1998.

Wound—Evidence-Based Interventions



Catherine Fisher, BSN, RN, CWOCN, , Colleen Dominy, AAS, RN, , Wendy Nelson, RN, , and Janice Blair, BSN, RN, , Nursing, Glens Falls, NY

INTRODUCTION: There is much in the literature regarding hospital-acquired pressure ulcers (HAPUs) and the strategies implemented on the journey to zero hospital-acquired pressure ulcer rates. With these resources available, our organization recognized that we had an opportunity for improvement to reduce HAPUs. OBJECTIVE: To build on current evidence-based strategies to reduce the number of HAPUs. METHOD: An interdisciplinary team, including nursing leadership, the hospital-acquired conditions (HAC) team, supply chain management, IT support, ancillary departments, and the CWOCN, was formed in 2013 to evaluate evidence-based practice strategies. With continuous revision, recommendations implemented include: (1) all RNs and NAs are assigned education modules that provide education about skin, nutrition, incontinence management, pressure ulcer prevention, support surfaces, and pressure ulcer staging; (2) change in skin and wound care product line; (3) Patient/Family Pressure Ulcer Education Brochure; (4) medical device–related pressure ulcer–reduction strategies; (5) new support surfaces; (6) new prevention heel boots; (7) two RN patient skin assessment on admission to hospital; (8) Braden Scale score to trigger nutrition support consultation; (9) change in incontinence management strategies, and (10) information badge cards. These new strategies build on our electronic medical record (EMR) notification to providers, use of resources within the EMR to guide therapy, skin and risk assessments, and provision of notification to the CWOCN of a documented pressure ulcer. RESULT: In 2012, there were 211 HAPUs in our facility. In 2013, 168 HAPUs; in 2014, 125 HAPUs; from January to September 2015, there are 55 HAPUs. This demonstrates a continuous reduction in HAPUs for our facility. RECOMMENDATION: Pressure ulcer prevention requires continuous attention to and revision of evidence-based strategies to sustain a reduction in hospital-acquired pressure ulcers. An interdisciplinary team is necessary to the care of the patient, reduction of HAPUs, and the success of the organization.

Agency for Healthcare Research and Quality. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality; October 2014.

Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/Hospital Acquired Conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel. J Wound Ostomy Continence Nurs. 2008;35(5):485–492.

Healthcare Association of New York State (HANYS). 2014. Pinnacle Award Nominations for Quality and Patient Safety.

New York State Partnership for Patients: A Partnership of the Healthcare Associations of New York and Greater New York Hospital Association (2013). Pressure Ulcer Prevention and Reduction: Evidence Based Practice.

Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society; 2010. WOCN Clinical Practice Guideline Series; no. 2.

Wound—Preventative Practices New



Catherine Milne, APRN, MSN, BC-ANP/CNS, CWOCN-AP, , Bristol, CT

BACKGROUND: Foam dressings have been shown to be efficacious in prevention of pressure ulcers (PU) when applied as part of a bundled comprehensive prevention program.1,2 Little literature exists on their role in maintaining skin integrity after the PU has resolved, as many times these dressings are removed, while the rest of the bundle remains unchanged. Silicone interface dressings have been shown to improve long-term skin outcomes in the burn patient3; it is unknown if this transfers to the pressure ulcer population. PROGRAM DESCRIPTION: An evaluation of 20 patients with history of repeated reinjury at the PU site in long-term care settings which use a 30-day 3 times daily application of moisture barrier creams or ointments after pressure ulcer resolution instead received a multilayered hydrocellular foam dressing* (MLHCFD) applied to the affected site for 30 days. Dressings were changed weekly or if needed for loss of integrity. Weekly skin checks occurred for 4 weeks then for an additional 4 weeks after the multilayered hydrocellular foam was discontinued and the patient was transitioned to usual care. RESULTS: Previous pressure ulcer sites remained intact while receiving the MLHCFD. The majority of dressings in the sacral area remained in place for 7 days. Only one patient reopened the site of the previous PU after transitioning back to a moisture barrier ointment. CONCLUSION: The action of the MLHCFD to promote skin integrity after injury is unknown but may be related to injured area remodeling, as seen in the use of silicone application to the burn patient. Although success is most likely multifaceted, dressing construction design may be a defining factor. Further studies are warranted. *Allevyn Life, Trademark of Smith and Nephew, Inc., Andover, Massachusetts.

Walsh N, Blanck A, Smith L, Cross M, Andersson L, Polito C. Use of a sacral silicone border foam dressing as one component of a pressure ulcer prevention program in an intensive care setting. J Wound Ostomy Continence Nurs. 2012;39(2):146–149.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haessler (Ed.). Perth, Australia: Cambridge Media; 2014:31. Emerging Therapies for Prevention of Pressure Ulcers.

Meaume S, LePillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol. 2014;24(4):435–443.

Continence—Evidence-Based Treatment and Management



Catherine Milne, APRN, MSN, BC-ANP/CNS, CWOCN-AP, , Bristol, CT

BACKGROUND: The potential for bacterial contamination of tubes containing ointments and creams are well known. During incontinence care, large amounts of fecal bacterial spread to intact and impair skin barrier as well as to the caregiver's gloved hands may occur. If the utmost attention to detail is not provided to, contamination of the moisture barrier tube tips and possibly, the barrier ointment or cream, may occur. Previous spray formulations used in wound care have a caregiver perceptions associated with reduced wound contamination.1 PROJECT PURPOSE AND METHOD: To determine if environmental bacterial and cross-contamination is reduced with a touchless spray delivery of protective barriers (TSB) * versus traditional rub on, flip-top, tube packaged protective barriers (TBT). Ten tubes of TBT used for a minimum of 1 week for patient care were cultured at the rim of the opening and compared with the cultures of the TSB nozzle. RESULTS: Cultures show a quantifiable difference between TSB and TBT, suggesting that cross-contamination is reduced with TSB. CONCLUSION: While all medication delivery systems can be a potential source of bacterial cross-contamination, those with spray delivery systems to prevent reintroducing bacteria to the incontinent patient with actual or potential loss of the transepidermal barrier should be considered when using barrier preparations. *Touchless Care® Clear Protectant Spray and Touchless Care® Zinc Oxide Protectant Spray, Crawford Healthcare, Inc., Doylestown, PA.

Weir D, Farley KL. Relative delivery efficiency and convenience of spray and ointment formulations of papain/urea/chlorophyllin enzymatic wound therapies. J Wound Ostomy Continence Nurs. 2006;33(5):482–490.

Wound—Management of Complex Wounds



Catherine Morrell, BSN, RN, , Continuum Home Health Care, Charlottesville, VA, and Mary Crandall, PhD, RN, , Continuum Home Health, Charlottesville, VA

Telemedicine has been shown as a feasible way to improve access to a wound expert, while not negatively impacting the quality of care provided to a patient. While multiple forms of telemedicine exist, videoconferencing provides real-time assessment and allows for a WOC nurse to recommend changes to the treatment plan in a timely manner. WoComm is a wound telemedicine program implemented at a large home health care agency located in central Virginia. The purpose of WoComm is to improve access to a WOC nurse for rural, homebound patients through teleconferencing. The goal of WoComm is to reduce rehospitalizations and emergency room visits related to wound deterioration, provide an expert visit to rural patients admitted to home health with a qualifying wound, and increase WOC nurse productivity. Patients with an open, nonhealing surgical wound, ulcer of the legs or feet, or a pressure ulcer, were eligible for WoComm. Initial program evaluation took place between June 2014 and June 2015. During this time, 64 unique patients were eligible and 18 were enrolled, 38 visits were attempted and 19 visits were successful. Rehospitalizations and emergency room visits related to wound deterioration decreased as a result of WoComm. No significant difference was found in clinical or financial outcomes between each group of patients. Multiple barriers were identified to implementation including: equipment failure, patient refusal, and coordination issues. WoComm did not significantly impact WOC nurse productivity. While multiple barriers to implementation were identified, participating nurses perceived WoComm to be a positive influence on care, and WoComm has impacted important patient outcomes. Further investigation into the barriers of implementing new technologies in the management of wounds in the home health population is needed to aid in the development of efficient home health wound management programs.

Hill ML, Cronkite RC, Ota DT, Yao EC, Kiratli BJ. Validation of home telehealth for pressure ulcer assessment: a study in patients with spinal cord injury. J Telemed Telecare. 2009;15:196–202. doi: 10.1258/jtt.2009.081002.

Zarchi K, Haugaard VB, Dufour DN, Jemec GB. Expert advice provided through telemedicine improves healing of chronic wounds: prospective cluster controlled study. J Invest Dermatol. 2015;135:895–900. doi: 10.1038/jid.2014.441.

Continence—Continence Clinics



Charleen Singh, MSN/ED, RN, FNP-BC, CWOCN, , Pediatric General Surgery, Sacramento, CA

In an effort to support children with constipation with or without soiling, a Children's Hospital in the North West created an opportunity to build a Bowel Management Clinic. To best utilize resources, the clinic is structured so that an advanced practice nurse with certification in continence leads the clinic, which is supported by pediatric surgeons, organizational leadership and ancillary staff. The bowel management clinic is part of pediatric colorectal surgery. Over the course of the year, the pediatric bowel management clinic has grown to see children on a regular basis and intake new cases every month. The early successes of the program have been measured by the number of referrals which reflect community awareness, quality of life for children in the program, and parent satisfaction. Building a sustainable clinic required collaboration from partners within the organization and the medical community. Having the unique opportunity to have the brick and mortar in place to build a program allowed the focus to shift to developing the quality of the bowel management program. The first step was to reach out to an established program to train staff. The next step was creating awareness of the program and developing referral systems which quickly and efficiently got children to the clinic. Established infrastructure of the organization allowed for housing of children and transportation at little to no cost. Unforeseen barriers to overcome included the impact on day-to-day operations with the increased number of children and the impact on high commodity resources. Developing a pediatric bowel management clinic has had a positive impact on children, provided a resource for community practitioners, and created a support of continuum of care for the colorectal surgery service.

Baþgöl Þ, Aydýn S, Beji NK. Developing roles of nurses in incontinence care. Global J Adv Pure Appl Sci. 2014;4.

Gordon D. PEBBLES: a family-centred, community-based continence service improving bladder and bowel health in children with disabilities in Western Australia: a protocol paper; 2014.

Palfrey S. Children's urology and continence nurses community. Health. 2012.

Martins G, Minuk J, Varghese A, Dave S, Williams K, Farhat WA. Determinants of paediatric bladder bowel dysfunction severity: a pilot study. J Pediatr Urol. 2015.

Tappin D, Nawaz S, McKay C, MacLaren L, Griffiths P, Mohammed TA. Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling. BMC Pediatr. 2013;13(1):193.

Professional Practice—Restructuring in Health Care Settings, Strategies for Survival



Charleen Singh, MSN/ED, RN, FNP-BC, CWOCN, , Wound Ostomy Program, San Jose, CA

Recognizing the need for nurses to have education in the subspecialty areas of wound ostomy and continence a Nursing Program in the North West State offered to support the build of a wound ostomy program. The Nursing Program championed the University to support a one of a kind wound ostomy program that integrates technology and traditional teaching methods. To support the success of the program, the educators of the program formed a community task force to gain insight on what the program should look like. Over the course of several years of planning, the Nursing Program offered the first course in the Fall of 2014 to bachelor's prepared nurses and has been able to sustain the program for 5 semesters. Early evaluation of the program has demonstrated continued engagement with the task force, meeting the expectation of the students and unexpected engagement with prospective employers. The students in the program range in years of experience, areas of practice, and levels of education. Anecdotal reports from the local ostomy support groups demonstrate enthusiasm and gratitude for the program.

Beitz JM. Specialty practice, advanced practice, and WOC nursing: current professional issues and future opportunities. J Wound Ostomy Continence Nurs. 2000;27(1):55–64.

Doughty D. Integrating advanced practice and WOC nursing education. J Wound Ostomy Continence Nurs. 2000;27(1):65–68.

Taggart E, McKenna L, Stoelting J, Kirkbride G, Mottar M. ). More than skin deep: developing a hospital-wide wound ostomy continence unit champion program. J Wound Ostomy Continence Nurs. 2012;39(4):385–390.

Wound—Product Selection and Innovations



Anuradha Godavarty, , and Suset Rodriguez, BS, , Department of Biomedical Engineering, Miami, FL; Charles Buscemi, , Nicole Wertheim College of Nursing and Health Sciences, Miami, FL; Maanasa Jayachandran, MS, , Jiali Lei, BS, and Elizabeth Solis, BS, , Miami, FL; Francesco Perez-Clavijo, DPM, , Doral, FL; Stephen Wigley, DPM, , North Miami, FL

Lower extremity wounds currently afflict over 6 million persons in the U.S. Among the elderly, the prevalence of chronic limb ulceration approaches 15% and is increasing. To date, clinicians employ visual inspection of the wound site during its healing process via monitoring of surface granulation. In some cases, surface granulation may not be an implication of internal healing. There is a need to develop a point-of-care, low-cost imaging tools that can objectively determine if a wound is healing or not. Herein, a portable, low-cost, noninvasive, and non–contact-based near-infrared optical scanner (NIROS) has been implemented to optically differentiate healing from nonhealing wounds. Noncontact, nonradiative real-time imaging was performed on diabetic subjects with lower extremity wounds (eg, diabetic foot ulcers, venous leg ulcers). The near-infrared optical images acquired from the wound site were processed to obtain optical contrast ratio between the wound and its background under various conditions of experimental conditions. Preliminary analysis from 20 wounds showed a sensitivity of 92% and a specificity of 97% in differentiating a wound as healing or nonhealing. A portable, easy-to-use point-of-care near-infrared optical scanner demonstrated its capability to classify a healing from nonhealing wound. Future work will involve systematic assessment of not only lower extremity wounds, but pressure ulcers to determine their healing.

Godavarty A., Khandavilli Y., Jung YJ, Rao PNS. Non-contact optical imaging of healing and non-healing diabetic foot ulcers. SPIE BiOS. 2015:931802.

Godavarty A, Rao PNS, Khandavilli Y, Jung YJ. Diabetic wound imaging using a non-contact near-infrared scanner: A pilot study. J Diabetes Sci Technol. 2015;9(5):1158–1159.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Chenel Trevellini, MSN, RN, CWOCN, , Nursing Education Department, Roslyn, NY

BACKGROUND: A 300+-bed community hospital conducted Incontinence Associated Dermatitis Severity Instrument (IADSI) validation study in 2014. The researchers evaluated IADSI instrument for interrater and intrarater reliability. The data collected revealed a 0.96 intraclass correlation coefficient when comparing simultaneously scored assessments of 20 registered nurses, with those of CWOCN specialist. Incontinence-associated skin damage (IASD) is a precursor to pressure ulcer development. Currently, there is no existing national, regional, or local database of IASD prevalence collected, shared, or reflected in an established benchmark. A National benchmark would be beneficial in identification of problem of IASD and drive clinical practice changes to prevent and treat IASD. QUESTION: What is the prevalence of IASD in the acute care inpatient setting, specific to parameters of IASD present on admission, IASD hospital acquired, and IADSI score. METHODS: A specially trained team of registered nurses, comfort care providers (CCP), and patient care associates (PCA) conduct data collection during monthly point prevalence study. Each team consists of team leader, RN, and CCP or PCA, 10 teams total. Team responsibilities include completing head-to-toe skin assessment, room safety check, and concurrent chart review for each patient. In addition, patients with incontinence are assessed and scored with IADSI instrument, which is completed by team RN. Monthly data is collected, analyzed, and trended, providing relevant clinical insight to IASD prevalence, IADSI score, and differentiation of POA or hospital acquired. OUTCOMES: Preliminary data utilizing 6 months of monthly point prevalence metrics reveals 12% prevalence of IASD during monthly point prevalence studies. The severity of injury ranged from 0 to 43 utilizing the IADSI assessment tool. Hospital-acquired IASD was 8.0%. CONCLUSION: System and process development to accurately collect data related to prevalence of IASD will help establish a national benchmark which will contribute to improvements in patient skin safety.

Borchert K, Bliss D, Savik K, Radosevich D. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Continence Nurs. 2010;37(5).

Trevellini A, Grossmann P. The Incontinence-Associated Dermatitis and its Severity Instrument (IADSI): validation of tool in the clinical setting. J Wound Ostomy Continence Nurs. 2015(suppl).

Wound—Preventative Practices New



Jennifer Delozier, BSN, RN, PCCN, CWCN, , PCU, Paoli, PA, Cheryl Freese, RN, , ICU, Paoli, PA, Kathleen McLaughlin, MSN, RN, CWOCN, , Staff Development, Paoli, PA, and Eric Eleftherakis, RRT, , Respiratory, Paoli, PA

Hospital-acquired pressure ulcers in the United States have declined over the past decade. However, during this same period medical device–related pressure ulcers have increased across the country. This same phenomenon has been witnessed at a suburban Philadelphia level II trauma center. Monthly prevalence and incidence studies at the institution revealed that the vast majority of hospital-acquired pressure ulcers were caused by medical devices, most notably cervical collars, tracheostomy flanges, arterial line splints, and BiPap masks. A process improvement team consisting of dermal defense champions, the educational team of the intensive care unit, and respiratory therapists initiated a literature search and developed strategies to eliminate this trend. A standard of care was developed for patients with a cervical collar: 2 nurses stabilize the patient's cervical spine while removing the collar, skin inspection is done, any reddened areas are noted and a silicone foam adhesive dressing is applied. This skin inspection is completed twice daily. A silicone foam adhesive dressing is applied to the web space of the hand prior to application of the arterial line splint. Skin beneath this dressing is inspected twice daily as well. A similar technique is used to protect bony prominences beneath a BiPap mask. The respiratory therapist partners with nursing in order to ensure skin inspection occurs every 2 hours beneath this device. The respiratory therapist also partnered with the trauma surgeons and physician assistants in order to eliminate suturing the tracheostomy tube flange to the skin, thus enabling good skin care and the ability to place a foam dressing beneath the flange if necessary. These interdisciplinary collaborations, along with rounding in the intensive care unit, has increased awareness that these ulcers are indeed preventable. This, in turn, has drastically reduced device related pressure ulcers to less than 1%.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines (2nd ed.). Osborne Park, Western Australia: Cambridge Media.

Niedrhauser A, Lukas C, Parker V, Ayellow E, Zulkowski K, Berlowtiz D. Comprehensive programs for preventing pressure ulcers: a review of the literature. Wound Care J. 2012;25(4):167–188.

Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, Van Den Berghe G. Incidence and risk factors for pressure ulcers in the intensive care unit. J Clin Nurs. 2009;18(9):1258–1266.

Ostomy—Psychosocial and Quality of Life Aspects



Christina Bumanlag, RN, BScN, ET, and Kimberly Colapinto, RN(EC), MN, CETN(C), , Division of General and Thoracic Surgery, Toronto, ON; Jessy Benjamin, MSW, RSW, , Department of Social Work, Toronto, ON; Alexis Shinewald, BA, ECE, CCLS, , Child Life, Toronto, ON, Canada

BACKGROUND: In 2001, an enterostomal therapist (ET) and social worker (SW) developed a Teen Ostomy Group at a Quaternary Children's Hospital in Toronto, ON, Canada, as pediatric ostomy support programs were not widely available. The meeting allows children 10-18 years and their family to share experiences living with a temporary or permanent ostomy. Over time personnel changes led to the group being supported solely by an SW. Families requested more resources and this led to the need for restructuring the group to better meet their needs. PURPOSE: To revitalize an existing ostomy support group by adopting a multidisciplinary approach and enhance resources available to inpatient and outpatient pediatric patients living with an ostomy and help families feel better supported by their health care providers. IMPLEMENTATION: In January 2015, the group was renamed Pediatric Ostomy Support Group and included 2 ETs, 1 SW, and 1 Child Life Specialist (CLS). Meetings were increased to bimonthly. Structure was changed to give time each meeting for guest speakers. Children are given separate time away from their parents with the CLS to increase comfort in sharing their experiences on life with an ostomy. Parents are given time to network and share experiences on supporting their children while facilitated by an ET and SW. OUTCOMES: A 6-month evaluation assessed efficacy of the changes made and 85% of respondents found the group useful in helping them live with their ostomy. Incorporating a multidisciplinary team enhanced the psychosocial care available to the group. Reintegration of the ET improved outpatient support and education. Group feedback led to the development of educational resources: ostomy care guideline, funding information, ostomy resource booklet, and ileostomy dietary guidelines to further enhance care. We hope that this encourages others to develop similar groups to enhance availability of pediatric ostomy support in the community.

Erwin-Toth P. The effect of ostomy surgery between the ages of 6 and 12 years on psychosocial development during childhood, adolescence, and young adulthood. J Wound Ostomy Continence Nurs. 1999;26(2):77–85.

Nicholas DB, Swan SR, Gerstle TJ, Allan T, Griffiths AM.). Struggles, strengths, and strategies: an ethnographic study exploring the experiences of adolescents living with an ostomy. Health Qual Life Outcomes. 2008;6:114.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Cynthia J. Sylvia, MSc, MA, RN, CWON, , Clinical Sciences, Charles Town, WV, Paula Gruccio, RN, MSN, CWOCN, , Vineland, NJ, and Heather Lindstrom, PhD, , Department of Emergency Medicine, Buffalo, NY

RATIONALE/PURPOSE: Hospital admissions are increasing, and admissions originating in the emergency department (ED) are upward of 40% in many facilities. From 1993 to 2006, ED-based admissions increased by 50%. The ED may be an important site to initiate pressure ulcer (PrU) prevention. OBJECTIVE: Describe demographic characteristics, pressure ulcer risk factors, and ED length of stay in a sample of hospital inpatients. METHODOLOGY: Data was analyzed from a PrU audit database maintained by a support surface manufacturer as a service for facilities conducting routine PrU prevalence audits. All data is deidentified and HIPAA compliant. Audit inclusion criteria were: acute care facility, audits from 2014 or 2015, data on minimum of 40 patients. RESULTS: A total of 6924 patients from 30 facilities are included in analysis. The patients were a majority female (52%), with a median age of 67 years (range 0-90, ages were truncated at 90 to protect patients' privacy). Patients' top five primary diagnosis categories were: cardiovascular (20%), pulmonary (15%), gastrointestinal (15%), neurological (13%), and skeletal (11%). Based on Braden Scale scores on admission, 47% of patients were considered to be at risk for PrUs. Specific PrU risk factors included fecal incontinence (35%), urinary incontinence (33%), Foley catheterization (47%), and PrU history (9%). 64% of patients spent some time in the ED prior to hospital admission, and 37% spent more than 4 hours in the ED. DISCUSSION: Many of the patients in the current sample were at risk for pressure ulcers and spent time in the ED prior to hospital admission. This suggests opportunities for initiation of PrU prevention measures in the ED. LIMITATIONS: The size of the database is small and limits generalization beyond the sample of acute care facilities that participate in the audit survey.

Denby A, Rowlands A. Stop them at the door: should a pressure ulcer prevention protocol be implemented in the emergency department? J Wound Ostomy Continence Nurs. 2010;37(1):35–38.

Dugart E, Videau MN, Faure I, Gabinski C, Bourdel-Marchasson I, Salles N. Prevalence and incidence rates of pressure ulcers in an emergency department. Int Wound J. 2014;11(4):386–391.

Naccarato MK, Kelechi T. Pressure ulcer prevention in the emergency department. Adv Emerg Nurs. 2011;33(2):155–162.

Pham B, Teague L, Mahoney J, Goodman L, Paulden M, Poss J, Li J, Ieraci L, Carcone S, Krahn M. Early prevention of pressure ulcers among elderly patients admitted to the emergency department: a cost-effectiveness analysis. Ann Emerg Med. 2011;58(5):468–478.

Schuur JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. N Engl J Med. August 2, 2012:391–393.

Professional Practice—Restructuring in Health Care Settings, Strategies for Survival



Cynthia Shephard, MSN, RN, CWOCN, , Nursing Practice, Education and Research, Baltimore, MD

Maintaining a multidisciplinary wound clinic is fraught with challenges. When the wound clinic at our large teaching hospital closed, the author proposed establishment of a mobile wound/ostomy nurse consult service to continue to utilize the expertise of our certified wound nurses. Many of our current patients were being referred within our own facility, to ambulatory clinics that were not fully prepared to absorb this workload. Three WOC nurses were already familiar with the patients and could provide a comprehensive introduction to support the new provider along with continuity of care for the patient. Furthermore, the WOC nurses were competent in the billing and compliance issues that envelop ambulatory wound care. Administration was supportive, acknowledging that this would also preserve a portion of the facility's lost revenue stream. We approached the task of transforming the brick-and-mortar clinic into a mobile service systematically over 2 months. A critical step was maintaining a reporting log to track volume and referral generation, as a tool to justify our value. Outcomes after 1 year have been universally positive: Monthly visits increased from 93 to 206. We built new relationships with providers across campus, which we regularly exploit to get patients access to necessary specialty services, of which the primary clinic provider is often unaware. Providers and patients are delighted that they can now obtain same-day wound care expertise. Nurses use the EHR to track patients across campus wherever they have appointments; closer oversight has led to better compliance by patients with evidence-based treatment plans, and to discovery of several instances of prescription errors and miscommunication between providers. The service has a positive impact on hospital revenue. In this expanded role, the WOC nurses facilitate communication between provider silos, provide continuity of care, and coordinate the services of multiple specialties, thereby increasing satisfaction among all stakeholders.

American Nurses Association. (2012). The value of nursing care coordination. White Paper.

Kim PJ, Evans KK, Steinberg JS, Pollard ME, Attinger CE. ). Critical elements to building an effective wound care center. J Vascular Surg. 2013;57:1730–1709. doi:10.1016/j.jvs.2012.11.112.

Meyers D, Peikes D, Genevro J, Peterson G, Taylor EF, Lake T, Smith K, Grumbach K. The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

Miller-Cox D. Wound care silo busting: building a service line across the continuum. Today's Wound Clin. 2014;8(4):12–14.

Rich E, Lipson D, Libersky J, Parchman M. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0010-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2012.

Ostomy—Clinical Outcomes



Debra Johnston, MN, RN, CETN(C), , Wound and Ostomy, Toronto, ON, Canada, Debbie Miller, MN, RN, CETN(C), , Oncology, Toronto, ON, Canada, Marg McKenzie, RN, CCRP, , Zane Cohen Centre for Digestive Diseases, Toronto, ON, Canada, and Monica Frecea, MScN, RN, CETN(C), , Enterostomal Therapy, Toronto, ON, Canada

Enhanced Recovery After Surgery (ERAS) is a multimodal program developed to decrease postoperative complications, enhance recovery, and promote early discharge. In the province of Ontario, Canada, a standardized approach to the care of patients undergoing colorectal surgery was adopted by 15 hospitals in March 2013. All elective colorectal surgery patients with or without an ostomy were included in the ERAS program targeting a length of stay of 3 days for colon surgery and 4 days for rectal surgery. It was important to ensure that the individual needs of patients requiring an ostomy were being met within this new health care delivery model, given that ERAS was becoming the standard of care. Different providers with varying levels of experience and expertise were caring for this vulnerable patient population and there was variation in the support available and offered to patients following their acute care discharge. The strategy to meet the patient care need has been 2-fold. First, a provincial ERAS Enterostomal Therapy Nurse (ETN) Network was established, which developed an evidence-based ostomy specific clinical practice guideline for ERAS patients requiring a fecal diversion. The second phase has been the individualized implementation of this robust clinical guideline by each ERAS hospital and associated community care provider grounded within the distinctive available resources in their area utilizing a standardized approach. This presentation provides participants with an overview of the work accomplished by this group over a 3-year period. The established clinical recommendations to standardize the nursing care of patients with an ostomy within the preoperative, postoperative, and discharge phases will be presented. The innovative ERAS ETN implementation strategies to garner interest and secure organizational support and commitment will be discussed. In addition, quality indicators will be highlighted as they will be utilized in future to evaluate the success and effectiveness of this initiative.

Adamina M, Kehlet H, Tomlinson GA, et al. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830–840.

Burton, et al. Impact of stoma care on enhanced recovery after colorectal surgery. World J Gastrointestinal Surg. 2011;3(1):1–6.

Hendren S, Hammond K, Glasgow SC, Perry WB, Buie WD, Steele SR, Rafferty J. Clinical practice guidelines for ostomy surgery. Dis Colon Rectum. 2015;58(4):375–387.

Younis J, Salerno G, Fanto D, Hadjipavlou M, Chellar D, Trickett J. Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme. Int J Colorectal Dis. 2012;27:43–47.




Deseret Faull, RN, , Children's Surgical Unit, SLC, UT, and Stacey Shelley, RN, MSN, MBA-HCM, , Wound/Ostomy, SLC, UT

PURPOSE: To create a process on an inpatient surgical unit in a pediatric hospital to improve nursing compliance with the pressure ulcer prevention (PUP) bundle to 90%. The impact on pressure ulcer recognition and care was measured. BACKGROUND: The location of 74% of these pressure ulcers is on the occiput, coccyx, heels, and peripheral intravenous (PIV) catheter site. In response, a PUP bundle was created. The surgical unit consistently had one of the lowest compliance rates. This rate was as low as 9.1% in September 2013. METHOD: The off-going and oncoming nurses simultaneously check the occiput, coccyx, heels, and PIV skin sites at shift change as a part of the bedside handoff process. Education was provided to the RN staff in January 2014 with a go live date of February 1, 2014. Four audit tools were used to determine compliance including blind audits, self-auditing, peer-auditing, and 2-man team audits. RESULTS: After implementation of checking the 4 skin sites in handoff, the surgical unit achieved 90% or greater PUP bundle compliance 21 of 29 months. Patients on the surgical unit have been pressure ulcer free since August 2014. During the months of June to September 2014, the surgical unit reported 23 patients with blanchable redness on the skin. CONCLUSION: To date, the surgical unit has continued to lead the hospital in bundle compliance since implementation. The surgical unit is the only unit to implement this practice. A neurotrauma unit will be starting implementation in October 2015. Recommendation is to implement this process hospital-wide.

Ostomy—Psychosocial and Quality of Life Aspects



Diane Bryant, RN, MS, CWOCN, , Mary Willis, MS, RN, CWOCN, , Ilene Fleischer, MS, RN, CWOCN, , and Linda Martin, MS, RYT, , Nursing, Boston, MA

The WOC nurses at a Boston hospital developed an Ostomy Peer Visitor program to support patients with new ostomies transitioning from hospital to home. Central to the program are BWH volunteers, experienced in ostomy peer visitation, who visit patients in their hospital rooms. After approval by the nursing directors and educators of the selected units, a welcome “tea” was held to introduce the Visitor and program to nursing staff of the units. The program was piloted for 3 months with 1 Visitor seeing patients. The Visitor's shift began with WOC nurses providing names and pertinent information about patients who may welcome a visit. To determine if a patient was interested and able to meet, the Visitor conferred with their RN. Thirty patients were visited during the pilot, including 11 ileostomies, 8 colostomies, and 11 urostomies. Visits averaged 25 minutes. The Visitor observed that many patients were concerned and fearful about being in public, accepting their body, and feeling normal again. Fewer asked about managing their ostomy care. Patients needed to tell their stories and were grateful for a compassionate listener who shared their medical experience. At the end of the pilot, a Survey Monkey with 8 questions was sent to nursing staff for feedback about the program. Results showed that respondents were supportive of the program and valued the Visitor as a knowledgeable resource with life experiences. Nurses stated that after visits, patients appeared calmer and happier, reassured, and grateful. The reason patients occasionally declined visits included being too tired or sick, or not ready to talk. Suggestions to improve the program included adding a male visitor, matching the type of ostomy, adding another visitor day, and telephone visits for patients who were discharged without a visit. The program will continue with plans to incorporate these suggestions for improvement.

Cross HH, Hottenstein P. Starting and maintaining a hospital-based ostomy support group. J Wound Ostomy Continence Nurs. 2010:37:393–396.

Dennis CL. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003;40:321–332.

Wound—Evidence-Based Interventions



Diane Wagner, MSN, BSN, RN, CWOCN, , Nursing, Philadelphia, PA

Pressure ulcer incidence in cardiac surgery patients is reported to be as high as 29.5%, due to their many intrinsic risk factors which include numerous comorbidities, advanced age, and compromised cardiovascular status. These factors are compounded by the factors related to the perioperative period including prolonged immobility, numerous lateral transfers, and hemodynamic changes. Previous projects at this 571-bed academic medical center implemented a prophylactic silicone dressing on high-risk patients in 2 different ICU settings, resulting in a 64% and 24% reduction in the SICU and MRICU units from 2009 to 2013. However, with a 12-month incidence rate of 8.7%, further preventative measures were required in the CICU population. The heels and the sacrum are the highest anatomical location for OR PU. A review of literature indicated randomized controlled trials showing success in reducing both sacral and heel HAPU with the use of prophylactic dressings in the ED and OR populations.1,2 Additionally, the NPUAP 2014 Guidelines also recommend considering their use.3 Consequently, we expanded preventive interventions by adding the use of the heel dressing and by applying both the sacral and heel dressing prior to surgery, in addition to our prior policy for their application for the duration of their ICU stay. Skin assessments were performed preoperatively, postoperatively, and daily. Other Bundle components already in effect included: off-loading, nutritional support, specialty beds, repositioning, and moisture management. Sixty-five patients were followed from September through December 2014. One patient developed a pressure ulcer (immediately postop). No pressure ulcers on the sacrum or heels have been noted in the 9 months since initial implementation of the dressing. In conclusion, based on our experience and review of best-practice guidelines, use of prophylactic dressings is recommended: throughout the perioperative period on cardiac surgery patients and on the sacrum and heels of all ICU patients.

Santamaria N, Gerdtz M, Sage S, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J. 2013. DOI: 10.1111/iwj.12101.

Castelino I, et al. Reducing perioperative pressure ulcers in thoracic, cardiovascular and spinal surgery patients: achieving zero incidence is possible! J Wound Ostomy Continence Nurs. 2012;39(3S):S17.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Haesler Emily, ed. Perth, Australia: Cambridge Media; 2014:77–78.

Ostomy—Psychosocial and Quality of Life Aspects



Ekta Vohra, CWON, , New York, NY

PURPOSE: Ostomy creation can be a life-altering experience that affects patients on many levels. Emotionally, patients are challenged to cope with this new way of life. Additionally, new ostomates are encouraged to participate in the mechanics of pouching. These 2 factors combined, patients often feel overwhelmed when transitioned into the home setting. The ostomy focused discharge phone call (OFDPC) is a tool that reinforces the continuity of care. A series of questions addresses the specific type of ostomy, needs/issues, challenges, comfort level, and home care services. The purpose of this innovation study is to improve WOC nurse practices and bridge the potential knowledge gap that can exist when a new ostomate is discharged. SUBJECT AND SETTING: The study was conducted at a large urban academic institution. Fifty new ostomates (parents of infants to elderly) were called by the WOC nurse within a 1–2-week time period after being discharged from the hospital to the home setting. A series of questions was asked in relation to their type of ostomy, comfort level, and home care services. OUTCOMES: Conducting ostomy focused discharge phone calls showed an increase in patient satisfaction and an improvement in CAHPS scores.

Beaver K, Wilson C, Procter D, Sheridan J, Towers G, Heath J, Susnerwala S, Luker K. Colorectal cancer follow-up: patient satisfaction and amenability to telephone after care. Eur J Oncol Nurs. 2011;15(1):23–30.

Edis H. Meeting the needs of new ostomists: a patient evaluation survey. Br J Nurs. 2015;v.24(stoma suppl):S4–S12.

Richbourg L, Thorpe JM, Rapp CG. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs. 2007;34(1):70–79.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Elise Frans, MN, RN, CWON, , and Janet Regan-Baggs, DNP, RN, ACNS-BC, CCNS, CCRN, , Patient Care Services, Seattle, WA; Nicole Johnson, BSN, RN, CCRN, , Amy Haverland, MN, RN, CCRN, , Courtney Crocker, BSN, RN, CCRN, , and Chloe Rahmun, BSN, RN, CCRN, , Medical-Surgical-Transplant ICU, Seattle, WA; Lisa Wheeler, BSN, RN, CCRN, , Cardiothoracic ICU, Seattle, WA

PURPOSE: To improve knowledge and pressure ulcer prevention practices of direct care nurses through an educational initiative in 2 intensive care units. BACKGROUND: During a quarterly pressure ulcer surveillance in 2014, the cardiothoracic and medical-surgical transplant ICUs in an urban academic medical center had a unit-acquired pressure ulcer prevalence rate of 17.9%. DESCRIPTION: Clinical nurse specialists (CNS), nurse managers, assistant nurse mangers, and 2 staff nurses from each ICU's skin team designed an initiative which included weekly rounding and small group education with staff nurses. The 2 skin team nurses, managers, and assistant managers each received 1 hour of education from the wound and ostomy CNS to reinforce content and identify the best ways to deliver education. Over 4 weeks, the team rounded in pairs on day-and-night shifts to educate staff nurses in groups of 1 to 3. OUTCOMES: Surveys measuring knowledge and self-reported practices were disseminated to all staff nurses before rounding and then 1 and 4 months after. In most instances, knowledge and self-reported practices increased at 1 month. At 4 months, knowledge and practices had declined slightly but were still higher than baseline results. Quarterly pressure ulcer prevalence data were evaluated before and after the intervention. Pressure ulcer prevalence rates decreased from 17.9% in quarter 1 of 2014 to 2.5% in quarter 1 of 2015. CONCLUSIONS: There was no statistically significant improvement in knowledge or in self-reported practices pre- and postintervention. Pressure ulcer prevalence had a strong decline over the course of the year following the intervention which may be attributed to the focus that this educational initiative directed at the problem. Ongoing collaboration of the skin care team with direct care nurses may have also contributed to the results.

Professional Practice—Computer Software Applications: Database Programs; Statistical Packages; Educational Resources



Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN, , Hollis Hills, NY; Barbara Delmore, PhD, RN, CWCN, DAPWCA, IIWCC-NYU, , NYU Langone Medical Center, New York, NY; R. Gary Sibbald, BSc, MD, FRCPC, (Med, Derm), MACP, FAAD, MEd, FAPWCA, , University of Toronto, Toronto, ON, Canada; Hiske Smart, RN, MA, PG Dip (UK), IIWCC-CAN, , and Gulnaz Tariq, RN, BSC, PG Dip (Pak), , Mississauga, ON, Canada

AIMS: To describe the 3-year impact of the International WoundPedia™ Wound Care Courses in Manila, the Philippines. METHODS: The International WoundPedia™ Wound Care Basic and Intermediate Courses are 2-day interdisciplinary courses that have been held in Manila since 2013. Course content is independent of the unrestricted educational grant provided by industry to fund the course. In 2013, only 2 basic courses were provided, while in 2014 and 2015, 1 basic and 1 intermediate case-based course were given. The course format includes interactive adult education principles. Course participants are taught how to make monofilaments using equipment available in the Philippines and perform an assessment to determine the high-risk diabetic foot along with other clinical skills. RESULTS: Over 200 health care professionals have completed the courses. Monofilaments are now available for use in practice settings as part of diabetic foot screening using the simplified 60-second diabetic foot screening tool. Collaboration with the military has resulted in an improvised suction with gauze and film dressings as NPWT principles to heal soldiers' wounds. An article on wound healing and the course was included in the Military Nursing Journal. Funding has been obtained to open a wound clinic at the charity hospital. Interest in skin and wound care and membership in an international nursing association have significantly increased. CONCLUSION: With over 200 graduates in the Philippines, WoundPedia™ has enhanced wound care practice in a resource challenged country.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Elizabeth Savage, MSN, APRN, ACNS-BC, CWON, , Wound & Ostomy Nursing Service, New York, NY, Sarah Lebovits, RN, MSN, ANP-BC, CWOCN, DAPWCA, IIWCC-NYU, , Wound and Ostomy Nursing Service, New York, NY, and Barbara Delmore, PhD, RN, CWCN, DAPWCA, IIWCC-NYU, , NYU Langone Medical Center, New York, NY

PURPOSE: To increase nursing autonomy, decrease inappropriate referrals to the wound, ostomy and continence (WOC) nursing service, thereby decreasing healthcare dollar expenditure and improving nursing workflow. BACKGROUND: Accurate identification of suspected deep tissue injury pressure ulcers is imperative for proper coding, regulatory reporting, and timely, evidence-based appropriate intervention. At our facility, a large metropolitan academic medical center, identification of the different etiologies of skin discoloration differential, particularly purple and/or maroon coloration, was identified as confusing to the nursing staff, especially in patients with darker skin tones. Nursing staff frequently referred all noted purple and/or maroon discoloration to the WOC nursing service. Uncertainty in identification by the bedside nurse prompted unnecessary referrals thereby increasing healthcare dollars, slowing nursing work flow, and verbalized frustration by the nursing staff. Additionally, nursing staff duplicated efforts by involving skin care nurse champions to assist in the identification and accurate documentation of many purple/maroon skin discolorations even after WOC nursing service evaluation. This issue prompted the need for the WOC nursing service to review the literature for comparison of different skin discoloration etiologies, develop, and present an educational intervention. METHOD: A quick-reference guide and educational tool for bedside staff use was developed to assist in accurate identification, documentation, and appropriate treatment/interventions. This guide included a pictorial grid with definitions, etiology and treatment options for accurate documentation and treatment choices. OUTCOMES: Improved etiology descriptions by staff of skin discolorations as seen through electronic medical record documentation and notification to the WOC nursing service. Additionally, there is a decrease in inappropriate referrals to the WOC nursing service concerning purple skin discoloration not related to pressure damage.

Black J. Deep tissue injury: state of the science. Grand Rounds Presentation lecture; Virginia Commonwealth University Medical Center; December 3, 2010; Richmond, VA.

Sullivan R. A 5-year retrospective study of descriptors associated with identification on stage I and suspected deep tissue pressure ulcers in persons with darkly pigmented skin. Wounds. 2014;26(12):351–359.

Yastrub DJ. Pressure or pathology: distinguishing pressure ulcers from the Kennedy Terminal Ulcer. J Wound Ostomy Continence Nurs. 2010;37(3):249–250.



Emily Greenstein, CWON, , Nancy Moore, CWON, , Shari Lee, CWON, , and Nikki Oliver, CWON, , Fargo, ND; Nikki Fischer, RN, BSN, , Wound Care, Fargo, ND

In 2011, the hospital-acquired pressure ulcer prevalence rate at a large Midwestern Academic Medical Center averaged 4.42% compared to the national benchmark average of 2.35%. With the higher than benchmark averages, the WOC nurse team decided to complete a root-cause analysis of the numbers. One thing that was discovered was there were no standards for skin assessment and documentation on hospital admissions. This led to the possible conclusion that some of the pressure ulcers being reported as hospital acquired were actually community acquired. In March 2013, the WOC nursing team implemented the 2 registered nurses (RNs) or “4 Eyes on Skin” assessment on all admissions and unit transfers. Using an electronic medical record, any skin issues and/or pressure ulcers were documented and signed off by 2 registered nurses. The outcomes were positive with a downward trend in prevalence. Since 2013, the 2 RN skin assessment has become a standard of care that has spread through the hospital enterprise. In 2013, the pressure ulcer prevalence rate was 1.47% and has remained under the benchmark number to date, which can be attributed in part to the implementation of the 2 RN admission skin assessment.

NDNQI: Preeminent Global Nursing Quality Measurement Program. Published 2011.

NPUAP. Pressure Ulcer Prevention & Treatment Clinical Practice Guideline. Washington, DC: NPUAP; 2009

WOCN Society Professional Practice Manual, Scopes and Standards of Practice, 4th ed.

Ostomy—Product Selection and Innovations



Ferne Elsass, MSN, RN, CPN, CWON, , Norfolk, VA

PURPOSE: Ostomy care presents numerous challenges to staff and patients. Nurses without special training or extensive experience may find the provision of ostomy care to be a fear-producing, confidence-reducing activity. This is especially true when working with a pediatric population whose ostomies often require highly specialized and individualized care routines. One free-standing children's hospital became increasingly aware that ostomy care and product choice had become a significant problem. Staff, patients, and families were becoming increasingly anxious about ostomy pouch changes related to delays in obtaining products, not providing patients and their families the correct product, and faulty pouch placement. Educational material was not readily available and the limited knowledge base of the nursing staff led to poor patient outcomes such as leakage, skin breakdown, and a fear of pouch changes. The use of incorrect products led to product waste and financial cost incurred by the facility. OBJECTIVE: A quality improvement project was developed that included education and a specific tool to decrease anxiety and improve outcomes. The education emphasized basic ostomy care, product selection, and product application. The main tool is an ostomy kit assembled in material management in a “go bag” that provides the necessary materials for both first-time and established ostomy patients. Ostomy kits are stocked in the patient units and are equipped with supplies necessary to apply an ostomy appliance along with materials to educate the family. OUTCOMES: Preliminary polling of nurses indicates that there is decreased anxiety when selecting ostomy products for patients. There is a time-saving component and a possible cost saving for the hospital with decreased product waste. More formal data will be collected over the next few months to evaluate the effectiveness of this quality improvement project.

Ostomy—Psychosocial and Quality of Life Aspects



G. Roxanna Lupien, MS, RN, CNL, CWOCN, CFCN, and Radoslava Stoddard, BSN, RN, CWON, CFCN, , Nursing Administration, Nursing Practice and PI, St. Louis, MO

We identified an opportunity for improvement in our level 1 trauma, an academic medical center where we create an estimated 60 new ostomies annually. Approximately one-third of our registered nurses employed have completed the nursing residency program. Prior to initiating our performance improvement project, nurses in the residency program received a 30-minute canned lecture on basic ostomy and nursing diagnoses. Patients indicated the nurses didn't know how to pouch their stomas or answer their questions. Our novice nurses identified a lack of self-confidence when caring for the ostomate. We developed an educational program to address these needs in the form of the Ostomy Workshop. We presented a PowerPoint lecture on basic ostomy: types, reasons for stoma creation, nursing assessment, diagnosis and care planning. The second part of the workshop includes volunteer members of the United Ostomy Association of America (UOAA), Greater St. Louis Support Group, who shared their personal experience and, pouching techniques, and showed their supplies, and, upon request, their pouched stomas with the novice nurses. This section was interactive with opportunities for question and answer. The final part was hands-on with pouching supplies. Our ostomy industry representative distributed modeling clay, paper plates, measuring guides, scissors, and pouching supplies on our formulary. The nurses paired up to create a stoma, to practice pouching, and to acclimate themselves with the supplies. We asked the nurses to complete pre- and postworkshop surveys to evaluate their learning. We looked at attitudes and beliefs toward managing the patient with an ostomy and nurses' confidence in their knowledge, skills, and ability to obtain correct supplies. The surveys indicated effective learning, improved attitudes, and increased self-confidence in caring for the patient with an ostomy.

1. Huddleston Cross H, Roe CA, Dongliang W. Staff nurse confidence in their skills and knowledge and barriers to caring for patients with ostomies. J Wound Ostomy Continence Nurs. 2014;41(6):560–565.

2. Richbourg L, Thorpe J, Rapp CG. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs. 2007;31(1):70–79.

Wound—Product Selection and Innovations



Glenda Brunette, MSN, RN, CWON, , Specialty Nursing, Charleston, SC

In today's rapidly changing healthcare arena, ensuring evidence-based, efficacious practice can be challenging. Miniscule print on lengthy package inserts compounds this issue. Currently, there is only one enzymatic debriding agent (Clostridium collagenase ointment) available which, if used appropriately, can be effective in removing necrotic tissue from wounds. However, there are many product interactions including wound cleansers and commonly used topical treatments which can render the Clostridium collagenase debriding agent partially to completely inactive. For example, both the floor stocked wound cleanser and antimicrobial roll gauze used in our academic medical center located in the Southeast negate the enzymatic activity by one hundred percent and were frequently noted to be used in conjunction with this product. In addition to rendering the product useless, this practice was fiscally irresponsible as the Clostridium collagenase is quite expensive at nearly $200 per 30-gram tube. Based on a research study published in 2012, a 1-page visual reference guide was created to help guide clinician practice in selecting appropriate topical management when using Clostridium collagenase ointment (Jovanovic et al, 2012). Our product formulary was reviewed in relation to the published research on product interactions and using a 1-page stop light type visual guide, products with no interaction were denoted using green. Products with 0-10% negative impact on product effectiveness were denoted using yellow. Those products noted to negate enzymatic activity by 10%-25% were highlighted in a light orange and any products which impacted effectiveness by greater than 25% were highlighted in red. This guide was shared with colleagues, posted on unit bulletin boards, and included in our intranet wound resources for staff reference. This simple tool has been useful in translating research into practice, thereby promoting better patient outcomes and avoiding wasteful, ineffective product utilization.

Jovanovic A, Ermis R, Mewaldt R, Shi L, Carson D. The influence of metal salts, surfactants, and wound care products on enzymatic activity of collagenase, the wound debriding enzyme. Wounds. 2012;24(9):242–253.

Professional Practice—Computer Software Applications: Database Programs; Statistical Packages; Educational Resources



Diwi Allen, MS, , Barbara Collins, BS, RVT, , and Chester Edlund, BS, , R&D, San Antonio, TX; Gustavo Galan, MS, , IT Software Development, San Antonio, TX

Advancements in mobile technology have permeated many aspects of everyday life and are now being highly leveraged in the healthcare field. Thus, a novel mobile app* has been recently developed for major mobile device platforms that provide useful features and tools for clinicians at their immediate disposal. This mobile app is designed and developed based on clinician needs and input. Patient information is encrypted, securely transmitted, and stored via this mobile app, which meets the highest standards set by the Health Insurance Portability and Accountability Act. The Connect and Consult function of this new app* streamlines communication between the clinician and industry wound care experts by sharing wound images and descriptions in a standardized manner, which enables a productive discussion regarding potential treatment options. This can help alleviate frustrations caused by missed phone calls and possibly lessen the need for bedside consults. The Order Therapy function offers a mobile solution that simplifies and expedites the ordering of negative pressure wound therapy with the ability to submit a valid prescription through the app. The ease and simplicity of placing a therapy order via the app may help ease some day-to-day burdens. The Manage Outcomes function allows clinicians to share patient wound healing information, required by payers for medical necessity, in a quick, simple, and direct way. Insurance companies require healing metrics at regular intervals to enable the patient to continue benefiting from current therapies. Finally, the Product Guides feature gives clinicians instant access to the most current product information relevant to their needs. The combination of these features and tools in one easy-to-use mobile application is an industry first and is an example of recent technology advancements in the healthcare arena designed to positively affect the clinician experience. *iOn Healing™ Mobile App, V.A.C.® Therapy (KCI, an Acelity company, San Antonio, TX)

Professional Practice—Marketing Strategies to Staff, Administrators, Peers



Gwen Spector, BSN, RN, COCN, , Plano, TX, Melayne Martin, BSN, RN, CWOCN, , Parkland Health & Hospital System, Dallas, TX, and Leslie Everett, BSN, RN, CWON, , Wound Care Center/In-patient, Dallas, TX

In North Texas, we are privileged to have an experienced group of WOC nurses practicing across multiple hospital systems. Connecting and sharing of ideas has always been a challenge. Our south central region is a bit too large because it includes 5 states. Local area meetings are difficult to attend based upon location and time. Large hospital systems have individual meetings but are a bit too small, involving only their team. Like Goldilocks, we needed a solution that would fit our group just right. Using social media helped solve our problem. An online social media page allows area WOC nurses to connect at a central location without a password or membership fee. An updated, centralized list was needed for local WOC nurses and patients to access area resources. The social media site includes a place to ask questions, shared resources, WOC events and educational opportunities for nurses or patients, employment opportunities, a directory of WOC nurses, outpatient resources, and an ostomy trouble-shooting guide. To date, 94 nurses are listed in the directory. The group includes registered nurses and advanced practice nurses in acute care, industry, home health, nursing education, and care management. As of October 31, 2015, there are 65 page likes and 69 group members. Comments have been positive from both patients and colleagues. We hope to continue to modify and make the page fit WOC nurses in North Texas just right.

Barry J, Hardiker N. Advancing nursing practice through social media: a global perspective. OJIN: Online J Issues Nurs. 2012;17(3).

Caron B. Infographic: how healthcare professionals use social media. Healthcare IT News. Published 2012.

Prinz A. Professional social networking for nurses. Am Nurse Today. 2011;6(7):30–32.

Schmitt T, Sims-Giddens S, Booth R. Social media use in nursing education. Online J Issues Nurs. 2012;17(3).

Ventola C. L. (2014). Social Media and Health Care Professionals: Benefits, Risks, and Best Practices. Pharm Ther. 2014;39(7):491–520.

Wound—Product Selection and Innovations



Honey Lyn Lerias, BSN, RN, CWOCN, , Patient Education, Detroit, MI, Karen Smethers, BS, PharmD, BCOP, , St. Louis, MO, and Thomas Aquilla, , Office Operations, St. Louis, MO

Significant increase of 93% in the cost of enzymatic debridement with collagenase has greatly impacted continuity of care as majority of the facilities to include ECF, LTAC and Home Care had removed this product in their formulary. Ascension Health, one of the largest health systems in the country, is also impacted by this huge increase in cost. In FY2014 alone, it had spent an excess of $1.5 million on enzymatic debridement. An opportunity was identified to review the management of necrotic wound to determine the place of collagenase using clinical evidence. A group of experts composed of CWOCNs and pharmacists convened over a 4-month period to review and grade evidence-based literature for the management of necrotic wounds. Recommendations from the workgroup included the following (1) Follow a systematic approach for management of necrotic wounds with a guideline taking into consideration amount of necrotic slough area, presence of infection and character of wound base. (2) Reevaluation of wound by experts at least once weekly. (3) If current treatment plan remains ineffective with at least 2 weeks of treatment, consider surgery consult for sharp debridement. The workgroup developed supporting materials that was summarized in a PowerPoint presentation including an SBAR to provide background information regarding this initiative. This was formally approved through the Ascension Therapeutic Affinity Group and communicated to all health system clinical leaders for evaluation over a 14-day period. Once all concerns were addressed, approval by the Clinical Executive Committee and Ascension CMO was obtained. Ascension sites were given 90 days to implement this initiative. This systematic approach in managing necrotic wound generated positive outcomes since its initiation in February 2014 to include timely intervention that is safe and effective, increased patient satisfaction, and significant cost savings with an average of 57% every month, from $264,000 to $114,000 on enzymatic debridement alone.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Hongyang Hu, , Wound and Ostomy Care Center, Hangzhou

OBJECTIVE: To explore the application of Lean Six Sigma method to improve the chronic wound patient's wound care process in order to improve the efficiency of wound care by reducing the material and labor costs and in the meantime the wound infection and healing rate are no significant difference contrast to the original data. METHODS: Use the 5 steps of Six Sigma process to define the program, measure and analyze the data, improve the process, and control the result, using the 5S method and visualization method to manage the desktop staffs and data materials; change the working environment to effective use of space, improving the outpatient service by education material, visualize the clinic process to patient to avoiding mistakes while finding the patient recording charts; design the multifunctional dressing care trolley to reduce repeated walking; clarify and rebuild the treatment process, and improve the chronic wound dressing process. RESULTS: After 9 months, the average cost of dressing change material (gauze, aseptic package, normal saline) was reduced from 10.8 RMB to 8.1 RMB by 25%, and the dressing time was 24 minutes compared to formal time 32 minutes shortened by 25%, while the rate of wound infection is 15.14% compared to the original rate 14.47%, there is no significant difference. The healing time was 42.4 days is shorter to the original time. CONCLUSION: Application of Lean Six Sigma in wound care clinic effectively reduces the medical cost and improve the efficiency of wound care.

1. Ye Zengjie Teng a valuable (review), the Xiao Ming (Revision). Chronic wound detection method. J Nurs. 2014;(18).

2. Jiang Yufeng. Research progress of chronic wound healing in surface. Infect Inflamm Repair. 2011;12(1):59–61. DOI:10.3969/j.issn.1672-8521.2011.01.024.

3. Xiao Song Zhao in Dai warm, often Chen Ying. Lean Six Sigma in hospital management improved empirical research. Ind Eng Manage. 2010;(4).

4. Sun Na. Application of Lean Six Sigma in patients with safety process modification research. Third Military Medical University; 2012

5. Sun Na, Sun Jin. Study on the admission process of patients with Lean Six Sigma. China's Health Qual Manage. 2012;(4).

Wound—Product Selection and Innovations



James O'Reagan, BSME, MSME, , and Joseph Lazich, BEEE, , Research and Development, Greenville, SC

Low-air-loss mattress systems are used for the treatment and prevention of pressure ulcers (1). As an improved description, these mattresses are now being called support surfaces for microclimate management. A few test methods have been proposed to quantify the microclimate management performance of these mattresses (2-4). Recent research has resulted in a new test method that offers the potential of repeatable results that are easily understood by practitioners. The test methodology was developed in conjunction with the National Pressure Ulcer Advisory Panel Support Surface Standards Initiative. This test method differentiates the moisture removal capability of various support surfaces. The test method is relatively inexpensive to perform and does not require a high level of technical skill. The steady-state transmission of moisture from the simulated patient surface to below the mattress cover can be determined. The results allow a practitioner to select which support surface removes the amount of moisture he/she prefers for their clinical setting.

1. Ferrell B, Osterweil D, Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. JAMA. 1993;269:494–497.

2. Williamson R, Lachenbruch C, Vangilder C. A laboratory study examining the impact of linen use on low-air-loss support surface heat and water vapor transmission rates. Ostomy/Wound Manage. 2013;59(8):32–41.

3. Reger S, Adams T, Maklebust J, Sahgal V. Validation test for climate control on air-loss supports. Arch Phys Med Rehabil. 2001;82:597–603.

4. Figliola R. A proposed method for quantifying low-air-loss mattress performance by moisture transport. Ostomy/Wound Manage. 2003;49(1):32–42.

Ostomy—Evidence-Based Interventions



Tami Walker, BSN, RN, CWOCN, , Ambulatory Care Ostomy Nursing Services, Ann Arbor, MI, and Jane Theriault, BSN, RN, CWOCN, , Ambulatory Ostomy, Ann Arbor, MI

The new ostomate has complex education and care needs in the postoperative period.1 There are time, financial, and access constraints imposed by health systems and insurers that restrict ongoing assistance to meet patient needs. Additionally, patients receive ostomy care and education across various health settings. These factors can impact abilities to develop ostomy self-care skills. To promote seamless care, patients were asked to provide feedback regarding their experiences related to a new ostomy to identify care and education gaps across the care continuum. BACKGROUND: An Ostomy Steering team at a 1000-bed academic hospital, composed of nurses, physicians, and administrators, across the health system who intersect with the ostomy population, identified education and care needs of the ostomy patient across the continuum as problematic. This was evidenced by hospital readmissions related to dehydration and MASD, patient complaints about access to knowledgeable postdischarge care, and observed patient knowledge deficits with pouching technique errors accompanied by MASD as noted by WOC nurses at 4–6-week postoperative clinic visits. METHODS: A patient satisfaction survey was used to provide insight into gaps in care and education across the care continuum. RESULTS: Seventy patients responded to an 11-question survey from August 2014 to April 2015 at a 4–6-week postoperative visit. Patient surveys reflected 3 areas of concern: nursing knowledge in rehab and home care settings and patient dissatisfaction in providing independent ostomy care. IMPLICATIONS: As increasing knowledge about ostomy care can improve the skills of the bedside nurse,2 next steps will focus on improving communication and education with local SNFs and home care agencies.

1. O'Shea H. Teaching the adult ostomy patient. J Wound Ostomy Continence Nurs. 2001;28(1):47–54.

2. Cross H, Roe C. Wang D. Staff nurse confidence in their skills and knowledge and barriers to caring for patients with ostomies. J Wound Ostomy Continence Nurs. 2015;41(6):560–565.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Janet Mullen, BSN, BA, RN, CWOCN, CFCN, , University of Pittsburgh Medical Center Passavant Hospital, Pittsburgh, PA, Jessica Johnston, BSN, RN, CWON, , University of Pittsburgh Medical Center Passavant Hospital, Pittsburgh, PA, Sheryl Fulmer, BA RN CWON, , ET/Wound Skin & Ostomy Department, Pittsburgh, PA, Lisa Manni, MSN, RN NEA-BC, , Nursing Administration, Pittsburgh, PA, Jenn Linn, BSN RN, , Medical/Surgical ICU, Pittsburgh, PA, Christina Wall, BSN CCRN, , Cardiovascular ICU, Pittsburgh, PA, Constance Pearson, MPM, RN, CPHQ, , Pittsburgh, PA, and Glenn Hasulak, MCSD, , Information Services, Pittsburgh, PA

Our acute care nonteaching suburban hospital has a group of registered nurses and nursing assistants “Skin Savers” who represent their units in monthly skin care meetings and prevalence surveys. However, despite the involvement of the Skin Savers and wound, ostomy and continence (WOC) nurses, we were not able to meet the National Data of Nursing quality Indicators (NDNQI) quarterly benchmark for 200–299-bed hospital in 3 of 4 quarters. The purpose of this project was to exceed the quarterly NDNQI benchmark through decreasing prevalence by at least 25% within 1 year. A process to discover the incidence of HAPU was developed between bedside nurse, WOC RNs, and Quality Improvement to discover contributing causes of HAPUs and evaluate the pressure ulcer prevention protocol. The process was initiated by staff documenting a pressure ulcer in the electronic record, followed by the WOC RN validating the wound and further assigned the PU to the responsible unit (UAPU). Criteria were established by unit directors, clinicians and WOC RNs by using existing assessment policies. Data identified the units with the highest UAPU. In April 2014, an intraprofessional subgroup was formed to examine the cardiothoracic and medical/surgical intensive care units who were responsible for over 27% of patients with UAPU. Development of a HAPU follow-up form identified both intrinsic and extrinsic causative factors, thus increasing UAPU awareness to unit leadership. The HAPU follow-up form led us to development of a unit-based mini root cause analysis. In conclusion, we met the NDNQI benchmark 4/4 quarters. Our baseline average was 2.07 and our average in the last 4 quarters was 1.01—a 51% improvement, thus exceeding our goal. This project's ultimate goal was preventing hospital-acquired conditions by raising awareness to reduce pressure ulcer occurrence, and to improve clinical practice.

Bryant RA, Nix DP eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier Mosby; 2012.

Cox J. Predictive power of the Braden Scale for pressure sore risk in adult critical care patients: a comprehensive review. J Wound Ostomy Continence Nurs. 2012;39(6):613–621.

National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel; 2009

Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcer. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.

Wound—Preventative Practices New



Jennifer Turner, RN, BSN, CWON, , Wound Care Department, Morgantown, WV, and Cindy Demniak, RN, MSN, FNP-C, , Plastic Surgery, Morgantown, WV

PURPOSE: Purpose of project was identification and guideline development for multiple uses of low air loss (LAL) within the neonatal and pediatric population at a Magnet Designated Children's Hospital. BACKGROUND: Diaper dermatitis is one of the most common dermatological diagnoses in the neonatal and pediatric population. Diaper dermatitis has been identified in 25% of the general diaper-wearing pediatric population [1]. Alteration in skin integrity can cause physical pain and suffering to the child with mental anguish to the parents. Depending on the severity of the dermatitis and disruption in the skin, may result in increased length of stay and additional financial expense. OBJECTIVE: The CWON and FNP-C led the guideline development initiative with (1) identification of at risk patients, which would benefit from an alternative support surface, (2) development of guidelines to provide moisture management in the neonatal and pediatric patient population, (3) development of patient algorithm to assess the patients' Braden Q [2] or Neonatal Skin Condition Score [3], and Neonatal Abstinence Score [4] (NAS). Based on the algorithm outcomes, determination is made if LAL pediatric crib surface is appropriate for integration into the care plan. OUTCOMES: Integration of the low air loss pediatric surface was successful with guideline development for primary services that are able to identify at-risk patients and early therapy initiation. Use of the LAL pediatric crib surface has steadily increased since inception. Patients with diagnosed moisture associated diaper dermatitis demonstrated improved healing times of 1 week upon initiation of LAL therapy. A low air loss surface has shown to be effective in interrupting the cycle of contributory events leading to diaper dermatitis. Improved sleep pattern along with a decrease in NAS (from 11-14 to 5-8) have been associated with the integration of LAL for patients diagnosed with neonatal abstinence syndrome.

1. Ward DB, Fleischer AB, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med. 2000;154(9):943–946. doi:10.1001/archpedi.154.9.943

2. Curley MAQ, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res. January/February 2003;52(1):22–33.

3. Association of Women's Health Obstetric and Neonatal Nurses. AWHONN Neonatal Skin Condition Score Tool. Published 2007.

4. Western Australian Centre for Evidence Based Nursing & Midwifery, January 2007. Neonatal Abstinence Scoring System.

Ostomy—Clinical Outcomes



Jerri Drain, BSN, RN, CWON, , Clinical Programs, Bunch, OK; Bobbie Stallings, BSN, RN, CWOCN, , Clinical Program, Williamson, GA; Kimberly Smith, BS, RN, CWON, and Naomi Ward, BSN, RN, CWS, , Clinical Programs, Baton Rouge, LA; Kimberly Bare, RN, BSN, CWON, MBA, , Clinical Programs, Oceanside, CA; Monica Timko-Progar, BSN, RN, ET, CWS, , Clinical Education and Clinical Programs, Perryopolis, PA; Sandra Wright, BSN, RN, CWCN, FACCWS, LNC, , Supply Mgt, Baton Rouge, OK

Outside of ostomy specialty nursing, most clinicians find caring for a patient with an ostomy to be a complicated and challenging endeavor. The average nurse has limited experience with ostomy management and finds pouching an ostomy, or choosing an appropriate pouching product to be frustrating and confusing. While algorithms and pathways for ostomy care can be found in acute and long-term care facilities, in home health care, resources to support ostomy care at home are difficult to find. As a large Home Health Care Company with 10,000-plus caregivers that manage thousands of ostomy patients each year, our goal was to have a standardized approach to ostomy education and management to support nurses in early identification of stomal and peristomal complications, pouching problems, and provide standardized solutions for managing ostomy care in general, while improving utilization of formulary products. With the implementation of the Ostomy Algorithm Tool, nursing knowledge and confidence improved, utilization of resources increased, pouching practices improved, and cost reduced as the algorithm drove formulary compliance and appropriate product usage.

Professional Practice—Computer Software Applications: Database Programs; Statistical Packages; Educational Resources



Jessica Johnston, BSN, RN, CWON, , University of Pittsburgh Medical Center Passavant Hospital, Pittsburgh, PA, Janet Mullen, BSN, BA, RN, CWOCN, CFCN, , University of Pittsburgh Medical Center Passavant Hospital, Pittsburgh, PA, Sheryl Fulmer, BA RN CWON, , ET/Wound Skin & Ostomy Department, Pittsburgh, PA, and Yvonne Weideman, DNP, MBA, RN, CNE, , Pittsburgh, PA

Mention an in-service on skin care and many a nurses' eyes might glaze over. This may be due to beliefs that skin care is not a priority assessment or a belief that “they have heard this all before.” Yet prevention, identification, and treatment of skin issues, especially pressure ulcers, is a critical component of nursing care and therefore an important area for staff education. WOC nurses at one facility decide to use creativity to tackle nursing indifference to skin issues by creating a Skin Expo entitled: “It's Five O'Clock Somewhere.” The Skin Expo will be implemented in November of 2015. The purpose of the Skin Expo is to engage staff in education that will facilitate increased knowledge and attitude related to skin care. Specific objectives include involving staff in educational activities related to (1) the importance of skin care; (2) preventative skin care; (3) identification and differentiation of pressure ulcers from other skin issues; and (4) pressure ulcer prevention, identification, and treatment. During the Skin Expo, staff nurses will circle through stations, each one designed to embrace the Skin Expo “It's Five O'clock Somewhere” theme while engaging staff in the learning process. Sample stations include: “Toes in the Sand” related to foot care, “Changes in Attitudes, Changes in Latitudes” related to the importance of staff reporting/communication of skin issues. Upon completing the stations, nurses will be asked to complete a short survey about their experience at the Skin Expo. Feedback from the survey will be utilized to evaluate the effectives of the Skin Expo at engaging staff in their learning to facilitate changes in knowledge and attitudes related to skin care. If effective, the Skin Expo may be an innovative, creative way for other WOC nurses to market the importance of skin care.

Wound—Preventative Practices New



Jody Scardillo, DNP, RN, ANP-BC, CWOCN, , and Donna Truland, BS, RN, CWOCN, , Albany Medical Center, Albany, NY; Karen Riemenschneider, DNP, RN-BC, CWOCN, , Clinical Nurse Specialist, Albany, NY; Kristin Hazelton Hardy, RN, BS, CWOCN, , and Lauren Sheehan, RN BS CWOCN, , WOC Nursing, Albany, NY

TOPIC: Repositioning is vital for pressure ulcer prevention. It reduces the extent of pressure over susceptible parts of the body, thus lessening the risk of pressure ulcer development. Effective positioning is a clinical challenge, especially in high-risk populations such as bariatric, critically ill, and cardiovascular patients, with differences in quality, effectiveness, and availability of pillows to keep the patient in the position of choice. Literature review revealed limited current information. PURPOSE: To determine whether an alternative turning device, such as positioning wedges, would contribute to reducing hospital-acquired pressure ulcers in the surgical ICU and the vascular surgery unit and aid in more effective repositioning efforts. OBJECTIVE: To determine the efficacy of using positioning wedges in preventing hospital-acquired pressure ulcers and maintaining adequate side-lying positions. A trial was initiated in the surgical ICU and vascular surgery units. Three foam wedges were trialed on all patients over a 2-week period. Two were reusable and one was disposable. Education was provided to all staff. An evaluation tool was developed to assess the ease of use, ability to keep patient in the desired position, comfort, efficacy, and if the patient's skin remained intact. OUTCOMES: A total of 39 patients were evaluated using 3 different wedges. Two reusable wedges had high scores, while the single use wedge scored very low. Decision was made to implement the lower cost reusable product due to similar outcomes. Prior to the trial one unit had one facility-acquired pressure ulcer, while the second unit had 2. At the completion of the trial, both units had no new facility-acquired pressure ulcers. A plan was developed to implement a hospital-wide purchase. Education for use, an algorithm, and plan for environmental service cleansing was developed.

Brennan M, Laconti D. Using conformational positioning to reduce hospital-acquired pressure ulcers. J Nurs Care Qual. 2014;29(2):182–187.

Wound—Product Selection and Innovations



Julie Ho, RN, MS, CWCN, , wound, Westminster, CA

PURPOSE: Clinicians are often confused about the selection of support surface and the need for low air loss to provide pressure redistribution. The misconception about managing the microclimate and insensate vapor loss has resulted in the overuse of low air loss therapy. Patients who score a 1 on the Braden subscale for mobility and a 2-4 for moisture do not need the perceived added benefit from low air loss therapy. METHOD: A retrospective chart review of 125 patients was conducted using skin and wound assessment data. Patient's requiring a therapeutic support surface for pressure redistributing, immersion, and shear management was accomplished using a pressure redistributing mattress with therapeutic foam and air bolsters delivering alternating pressure. Long-Term Acute Care Hospitals eliminated rental use of low air loss with alternating pressure therapy and purchased therapeutic foam and air bolster mattresses for adjunct therapy for pressure ulcer prevention and treatment. Patient selection consisted of patients who score a 1 on the Braden subscale for mobility and a 2-4 for moisture do not need nor benefit from low air loss therapy. Using a standardized algorithm based on the Braden scale, patients were placed on the newly purchased mattresses eliminating the use of daily rental replacement mattresses. Patients who had pressure ulcers were followed for wound improvement, and remaining patients were monitored for any new hospital-acquired pressure ulcers. RESULTS: Implementation of alternating pressure therapy and elimination of combined low air loss and alternating pressure therapy resulted in optimal pressure ulcer outcomes as measured by wound healing scores, prevention, and wound maintenance. Additionally, the hospital benefitted financially through the cost savings from on-site support therapy availability. CONCLUSION: Effective pressure redistribution was accomplished cost-effectively with therapeutic foam and air bolster mattresses with alternating pressure eliminating the added feature of low air loss therapy.

1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers; Clinical Practice Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance; 2014:105–113.

2. Black J, Berke C, Urzendowski G. Pressure ulcer incidence and progression in critically ill subjects. J Wound Ostomy Continence Nurs. 2012;39(3):267–273.

3. Johnson J, Peterson D, Richardson R, Rutledge D. Hospital acquired pressure ulcer prevalence-evaluating low-air-loss-beds. J Wound Ostomy Continence Nurs. 2011;38(1):55–60.

4. Russell L, et al. Randomized clinical trial comparing 2 support surfaces. Adv Skin Wound Care. 2003;16(6):317–327.

* PressureGuard® Custom Care® Convertible by Span-America used with a control unit delivering alternating pressure.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Karaleigh Crouse, BSN, RN, CWOCN, , and Cathy Wittenauer, RN, BSN, CWOCN, , Wound/Ostomy, St. Louis, MO

Skin care and pressure ulcer prevention in a large level I trauma center in the Midwest can be daunting. As our hospital campus continued to expand, it became evident we needed to make a change in our Wound Department organization and prioritization.

Geographic rounding has been implemented by hospitalist physician groups for years with many successes. We hypothesized if our team of 6 wound nurses divided into 3 teams of 2; we could increase efficiency, facilitate nurse-to-nurse communication, improve coordination of care, and decrease hospital-acquired pressure ulcers by making a closer connection with units and their personnel. In 2013, our team implemented geographic rounding in our 3 “towers” where we determined 80% of our patients were located. We sent e-mails to the leadership teams on all the units introducing the concept of geographic rounding and the WOC nurses assigned to their units. The overall goal was to reduce hospital-acquired pressure ulcers by providing optimal wound/skin care, improving collaboration with staff, ancillary departments, and physicians. Surveyed responses of staff nurses and leadership teams after 18 months were overwhelmingly positive. Respondents agreed there was improved communication and coordination between our wound care team and physicians, care coordinators, and staff nurses related to skin care prevention and treatments. Geographic rounding has been a valuable key to decreasing our facility-acquired pressure ulcers from a high of 3.6% prior to the program to the most recent rate of 0.3%.

Wound—Preventative Practices New



Karen Turbett, CWOCN, CFCN, , Brentwood, TN

Challenge—In House Acquired Pressure Ulcers (IHAPUs) • August, 2013: Facility-acquired pressure ulcers = 4% to 5% (118 PUs in 49 communities). • No company-wide pressure ulcer prevention (PUP) plan for residents in skilled care—reactive vs. proactive. • Supply rooms: Inconsistent availability of PUP products. • The need for buy-in from community staff. • Cost to treat pressure ulcers—reported as $500 to $70,000 per ulcer—$11 billion annually in the US Plan—Pressure Ulcer Prevention Plan. • My company had established a goal of ≤ 2% IHAPUs. • Identified products for skin and wound care management. • worked with manufacturer representatives to develop quick reference guides and education about product use. • developed and implemented other PUP interventions. Implementation of Plan: October 2013 for all 49 communities. Protection and Prevention for all residents • On admission to skilled setting, long-term care or rehab all residents receive. • A set of skin care products depending on their individual need; pH-balanced hair and body wash, cleanser, moisturizer, barrier ointment or cream (bed confined, wheel chair confined) receive a kit and the ambulatory receive a kit. • silicone adhesive hydrocellular foam dressing applied to boney prominences depending upon individual identified risk factor (pressure ulcer risk tool identifier of ≤ 16 or any subscore identifier placing the resident at risk). • Orders for silicone adhesive hydrocellular foam dressing established to be written for prevention; assess dressing, surrounding skin and skin under dressing q shift and PRN for dislodgement. • Dietary consult for nutrition for all at-risk residents, new pressure ulcers, change of condition, and if resident is admitted with PUs. • Turning frequency.

• Support Surface/device. • Clinical Judgment. Results: December 2013:

75 IHAPUs. June 2014 Company 0.62% IHAPUs. (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Ulcer Alliance. Background, Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, 2nd ed. E, Haesler, ed. Perth, Australia: Cambridge Media; 2014).

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Kelly Chapman, MS, RN, CWOCN, , and Karen Colegrove, MS, RN, CCRN, , Robert Packer Hospital, Sayre, PA; Christine Nolan, MS, RN, , DNER, Sayre, PA

INTRODUCTION: Hospital-acquired pressure ulcers (HAPUs) are a serious adverse event and impact upon resources and patients' quality of life. The developments of HAPUs are associated with increased comorbidities, decreased quality of life, longer length of stay in the hospital, and financial burden. Critically ill patients are at greater risk for HAPU development due to their impaired physiologic status and prolonged periods of immobility. Evidence-based HAPU prevention requires multiple interventions and clinical team collaboration. Pressure redistributing support surfaces are one of the interventions necessary for HAPU prevention in the critically ill patient population. METHODS: This quality improvement (QI) intervention took place on a 26-bed intensive care unit (3 pods: medical; cardiac; trauma). The metrics utilized for the study included HAPU incidence per 1000 patient days for a period 10 months prior and 10 months after. The QI intervention consisted of selection and purchase of new beds for the 26-bed ICU, in addition to caregiver education on appropriate use of the beds. The facility's HAPU prevention bundle was continued as part of the standard of care. Standardization of bed technology utilization was the main focus of this QI initiative, ensuring standardization of technology and reduced confusion among clinical caregivers on appropriate use of the bed in relation to HAPU prevention through pressure redistribution, offloading, and repositioning. RESULTS: Ten months prior to the utilization of the new pressure redistribution mattresses, there were 13 HAPUs. Ten months after the initiation of the new mattresses, 3 HAPUs developed. DISCUSSION: Standardization of bed technology may have contributed to reduction in HAPUs, and helped ensure evidence-based best practices were provided at the patient's bedside.



Carla Williams, BSN, RN, ETN, , Primary Health Care, New Glasgow, NS, and Kim Slack, BSN, RN, ETN, , Acute Care, New Glasgow, NS

For people living with an ostomy and experiencing related wounds, access to enterostomal therapy services (ET) in our community was nonexistent in 2012. Feedback from the Ostomy Support group clearly identified that timely, efficient access to an ET was the greatest gap in service. With no additional funding, our task was to create a multiaccess service for patients and providers in our community. The guiding principle for this work was the right care provider, at the right time in the right location. A review of the ET, RN, and LPN roles revealed the need to develop a model of care that would support the guiding principle. An environmental scan identified potential ET resources in the community. Working collaboratively with leaders in acute care, primary care, and continuing care, a process review was conducted to identify barriers to and opportunities for improved access. Through public and private partnership, 2 points of community access were established. Persons living with ostomies requiring the expertise of an ET can now self-refer at no cost to the patient. Family practice physicians and surgeons are also referring patients to the clinics. This model has provided a continuum of care that supports improved patient outcomes and experience, reduction in readmission rates, and quality aftercare contributing to overall wellness in living. Implementation of the model has confirmed the great need for timely, efficient access to ET services.

Harris C, Shannon R. An innovative enterostomal therapy nurse model of community wound care delivery. J Wound Ostomy Continence Nurs. 2008;35(2):169–183.

Taylor M, Mcnicholas C, Nicolay C, Darzi A, Bell D, Reed J. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Safety. 2013:290–298.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Kimberly Smith, BS, RN, CWON, , Clinical Programs, North Charleston, SC, and Monica Timko-Progar, BSN, RN, ET, CWS, , Clinical Education and Clinical Programs, Perryopolis, PA

Wounds and wound care in general present a challenge to Home Health Care (HHC). In a recent article published in the Journal of Wound, Ostomy and Continence (JWOCN), out of 300,000 home health care episodes of care reviewed, 34% involved wounds and 60% of the episodes identified patients with bowel or urinary incontinence (1). These statistics are significant as wound care costs remain a large part of the home health spend. In addition, complications that arise from wounds such as infection contribute to the overall cost of HHC and impact the acute care hospitalization readmission rates. The use of a wound care specialist (WCS), including both WOC nurse and CWS, in acute and long-term care settings is common practice. WCSs in the HHC setting are few. Approximately 13% of WCSs practice in the HHC arena (2). Lack of knowledge about the specialty area of practice and confusion over how to best utilize the WCS's unique skill set in the home care environment continues to be problematic. Because of this, the value in placing a WCS on the HHA payroll and how that role should function remains a challenge. The authors tracked data for 11 months following five (5) WCSs in a large home health care company who functioned in a true “program manager” role. Data results confirmed higher levels of quality care were achieved consistently with increased referrals of both wound and ostomy patients. Acute care hospitalization (ACH) rates for wound-related infection were decreased, revenue per episode (RPE) increased, and supply costs decreased. Wound care specialists as program managers are a valuable asset to home care.

Westra BL, Bliss DZ, Savik K, Hou Y, Borchet A. Effectiveness of wound, ostomy and continence nurses on agency level wound and incontinence outcomes in home care. J Wound Ostomy Continence Nurs. 2013;40(1):25–53.

Scope and Standards for Wound, Ostomy and Continence Specialty Practice Nursing: A White Paper from the WOCN Society (2012).

Professional Practice—Restructuring in Health Care Settings, Strategies for Survival



Kristal Caringer Quimby, BSN, RN, CWCN, COCN, , Wound Ostomy Continence Care Services, Phoenix, AZ

Operational reform, streamlining, and cultural shift within our hospital system mandated a comprehensive review of our pressure ulcer prevention program (PUPP). The existing program lacked cohesion and revealed deficiencies in process and structure within the redefined system as reflected through outcomes. Evaluation created a sense of urgency that required innovative restructuring, the addition of value-added elements, and ALIGNMENT of key components. Outcomes and noncompliance with updated PRACTICE guidelines identified the need for the NEXT GENERATION PUPP known as APPLES: Aligning Partners Practice & Leadership to Elevate Skin. OBJECTIVES: • ALIGN LEADERSHIP with internal and external PARTNERS who bring expertise in compliance, health economics, and PRACTICE guidelines with unbiased evaluation and outcomes reporting. • ELEVATE existing Skin Champions to the role of expert PUPP PARTNERS as an extension of the WOC nurse. • Promote the role of hospitalists and PATIENTS as PARTNERS through collaboration and PRACTICE. • Optimize the EMR as a source of education that provides direction for implementation and documentation supported by updated Clinical PRACTICE Guidelines. • Maximize the EMR capability to provide 1-touch reporting by extracting and exporting data for compliance review, e-measures, and program evaluation. Outcomes: • LEADERSHIP as PARTNERS can review and respond to real meaningful data related to outcomes, costs, and program expansion. • The EMR and educational applications using finger-tip technology have produced an increase in PARTNER participation and knowledge. • “TOP 100” recognizes nurse experts as PUPP PARTNERS in PU identification, staging, prevention, and education. • Visual cues have enabled at-risk patients to be identified on and off the unit to ensure 24/7 prevention. • Ongoing EMR optimization has ALIGNED PRACTICE and documentation with evidence based guidelines. • The NEXT GENERATION PUPP is positioned for implementation as a program to optimize daily practice, allow continuous systematic review to cost-effectively improve quality and outcomes, and provide ongoing evaluation for sustainability and change.

1. Brindle CT, Creehan S, Black J, Zimmerman D. The VCU Pressure Ulcer Summit: collaboration to operationalize hospital-acquired pressure ulcer prevention best practice recommendations. J Wound Ostomy Continence Nurs. 2015;42(4):331–337.

2. Christopher MA, Madden-Baer R. The power of alignment: pioneering new collaborations during transformational change. Nurs Adm Q. 2015;39(3):192–198.

3. Miller SK, Sharma N, Abereg LC, Blasiole KN, Fulton JA. Analysis of the pressure distribution qualities of a silicone border foam dressing. J Wound Ostomy Continence Nurs. 2015;42(4):346–351.

4. Agency for Healthcare Research and Quality. Preventing Pressure Ulcers in Hospitals. October 2014. Rockville, MD: Agency for Healthcare Research and Quality. Accessed December 13, 2015.

5. Santamaria N, McCann J, O'Keefe S, Rakis S, Sage S, Tudor H, Ng AW, Morrow F. Clinical innovation: results from a 5-year pressure ulcer prevention project in an Australian University. Wounds Int. 2015;6(3):12–16.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Lara Leininger, BSN, RN, CWOCN, , WOC Nurse Consult Service, Chapel Hill, NC; Donna Brickman, BSN, RN, CWOCN, , John Motko, RN, BS, CWS, CWOCN, , Juliet Idiagbonya, BSN, RN, CWOCN, , Lisa Jenkins, BSN, RN, CWOCN, , Janet Rankin, BSN, RN, COCN, , and Barbara Koruda, BSN, RN, CWOCN, , Department of Surgery, Chapel Hill, NC

The WOC Nurse Consult service collected data on the hospital expenditures related to WOC nursing care of patients with enterocutaneous or enteroatmospheric (within an abdominal wound) fistulas. When managing fistulas WOC nurses assessment and treatment plan must address; containing the effluent, maintaining the integrity of the perifistular skin, and controlling odor. Additionally, we must attempt to establish a containment system that allows the patient to be discharged from the hospital. We collected data while caring for (13) fistula patients over (3) months. Our collected data categories included supplies used, number of WOC nurse bedside encounters, duration of the bedside encounters, and number of WOC nurses at the bedside. Supplies included types of pouches and accessories, skin treatment products, and negative pressure wound therapy (NPWT). We did not quantify interventions for nutritional needs or medications to slow output or control pain. We did note these related factors, as they affected our collected data. This quantification of supplies and time allowed us to measure the hospital costs of the WOC nurse caring for a fistula patient.

Davis KG, Johnson EK. Controversies in the care of the enterocutaneous fistula. Surg Clin North Am. 2013;93(Issue 1):231–250.

Franklin C. The suction pouch for management of simple or complex enterocutaneous fistulae. J Wound Ostomy Continence Nurs. July/August 2010:387–392.

Wound—Evidence-Based Interventions



Sue Girolami, RN, BSN, CWON, , Therapy Support, Inc., Cincinnati, OH, Lisa Corbett, APRN, BC, CWOCN, , Wound Ostomy Continence Program, Hartford, CT, Kara Couch, MS, CRNP, CWS, , Wound Healing and Limb Preservation Center, Washington, DC, Karen Bruton, RN, BScN MCISc-WH CETN(C), , Wound Clinic, Coburg, ON, Vickie Driver, DPM, MS, FACFAS, , Orthopedic Surgery, Boston/Charlestown, MA, Tay Ai Choo, CWS, , Plastic Surgery, Singapore, Paul Liu, MD, FACS, , Department of Plastic Surgery, Providence, RI, Lisa Gould, MD, PhD, FACS, , Wound Recovery and Hyperbaric Medicine Center, Warwick, RI, Paulo Da Rosa, BScN, RN, MClScWH, CETN(C), , London, ON, Jeremy Tamir, MD, FAPWCA, , Lee Wound Care and Hyperbaric Medicine Center, Fort Myers, FL, and Laura Bolton, PhD, , Surgery, Metuchen, NJ

Using evidence-based guidelines to inform wound management decisions improves outcomes (1, 2). Guideline differences in definitions and recommendations can confuse wound care professionals reducing consistency of care and outcomes. PURPOSE: Unify venous ulcer (VU) and pressure ulcer (PU) guidelines to improve the consistency of VU and PU management in meeting professional, patient, and wound needs across specialties and settings. METHODS: Using standardized processes to develop and update “guidelines of VU and PU guidelines” (3), the Association for the Advancement of Wound Care Guideline Task Force (AAWCGTF) collaborated with the Wound Healing Society, Canadian Association for Enterostomal Therapy, and six other organizations to form the International Consolidated Guideline Task Force (ICGTF) updating the 2015 ICGTF VU and PU Guidelines, based on all recommendations from all major relevant published guidelines. Independent multidisciplinary respondents completed an online survey formally rating each recommendation's clinical relevance (1-4 scale) and strength based on benefit-to-harm ratings (0-2 scale). Each recommendation was “clinically relevant” if its content validity index (CVI) was at least 0.75, i.e. 75% of participants rated it clinically relevant. It was “strong” if its strength of recommendation average rating exceeded 1.50. Systematic literature reviews identified up to 5 best available references supporting each recommendation based on published (3) standardized evidence ratings (A, B, or C). RESULTS: Both guidelines were designed to meet Institute of Medicine and AHRQ standards, in accordance with GRADE, AGREE, and BRIDGE-WIZ principles for developing high-quality, evidence-based guidelines. All recommendations included in each final guideline are clinically relevant (CVI > 0.75) and/or supported by the highest level of available evidence. CONCLUSION: The resulting unified, quality guidelines have the potential to improve the consistency of VU and PU care and outcomes, serving patients and interdisciplinary wound care professionals across all settings.

McGuckin M, Waterman R, Brooks J, et al. Validation of venous leg ulcer guidelines in the United States and United Kingdom. Am J Surg. 2002;183:132–137.

McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care. 2008;21(2):75–78.

Bolton LL, Girolami S, Corbett L, van Rijswijk. The Association for the Advancement of Wound Care (AAWC) venous and pressure ulcer guidelines. Ostomy/Wound Manage. 2014;60(11):42–81.



Laura Phearman, RN, BSN, , University of Iowa Children's Hospital, Iowa City, IA, Rebecca Harman, RN, MSN, , childrens and Womens Services, Iowa City, IA, and Jennifer Baker, RN BSN, , Womens and Childrens Services, Iowa City, IA

PURPOSE: The purpose of this evidence-based practice project was to implement assessment and interventions strategies to reduce pediatric pressure ulcers below NDNQI benchmarks in the PICU. OBJECTIVE/RELEVANCE/SIGNIFICANCE: House-wide quarterly pressure ulcer prevalence audits are completed. There has been an increase in pressure ulcers in the PICU since January 2014. STRATEGY AND IMPLEMENTATION: • Skin Team Advocate Resource (S.T.A.R.) members on the unit were encouraged and supported to complete the Wound Treatment Associate Program. • Collaboration with ECMO team to develop and incorporate enhanced education and protocols for skin care. Started in Summer 2014 and Development of order sets. • Additional education with PICU staff. • Improved handoff report between PICU and OR regarding positioning devices and protective positioning devices. • Including pressure ulcer prevention interventions in the nursing comments of the bedside nursing handoff section. • Pediatric Wound and Skin Specialty Nurse attending Division Bed Huddles. • Adaptation to routine nursing practices through nursing skin care protocols that could be instituted without orders heel protection developed. • Updating and distribution of unit specific tool kits for skin care and pressure ulcer prevention. • Online yearly inservice on pressure ulcer and moisture-related skin damage prevention. • Inservicing on new products for skin care. • Implement consult to the pediatric wound and skin specialty nurse when ECMO is started. • Developed skin care algorithms for bedside staff. Skin tear algorithm, dressing care, IAD algorithms. • Monthly “mini-audits” for the PICU. • Encourage the STARs who have completed the WTA program to become certified when the test is available. EVALUATION: With increased education and implementation of the current strategies, we are reducing the number of pressure ulcers and increasing the overall awareness of pressure ulcer prevention among the PICU staff.

Curley M, Razmus I, Roberts K, Wypij D. Predicting pressure ulcer risk in pediatric patients—The Braden Q score. Nurs Res. 2003;52(1):22–33.

Huffines B, Logsdon C. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues in Comprehensive Pediatr Nurs. 1997;20:103–114.

Lund C, Kuller J, Raines D, Ecklund S, Archambault M, O'Flaherty P. The neonatal skin care evidence-based clinical practice guidelines. AWHONN. 2007.

McCord S, McElvain V, Sachdeva R, Schwartz P, Jefferson L. Risk factors associated with pressure ulcers in the pediatric intensive care unit. J Wound Ostomy Continence Nurs. July/August 2004:179–183.

Schindler C, Mikhailov T, Fischer K, Lukasiewicz G, Kuhn E, Duncan L. Skin integrity in critically ill and injured children. Am J Crit Care. 2007;16(6):568–574.

Wound—Preventative Practices New



Valerie Grumme, RN, MSN, PhD candidate, , Jasmine Parker, RN, BSN, , and Phyllis McCall, RN BSN, , ICU, Hollywood, FL; Lea Crestodina, ARNP, CWOCN, CDE, , Wound Care, Hollywood, FL

PURPOSE/OBJECTIVE: The purpose of this performance improvement project was to evaluate the effectiveness of a shift-to-shift skin assessment protocol added to the existing bedside rounding conducted during shift change in a high acuity ICU at a large local community hospital. BACKGROUND/SIGNIFICANCE: Hospital-acquired pressure ulcers can significantly impact patient length of stay and mortality. In an era of value-based purchasing, hospital-acquired pressure ulcers can lead to substantial loss of reimbursement. From a holistic nursing perspective, pressure ulcers can be painful and debilitating, contributing to psychological and emotional distress that impacts quality of life and healing. METHODOLOGY/DATA ANALYSIS: Focused skin assessments, including all potential pressure areas, were added to the bedside rounding at shift change. Documentation of skin assessment was included in the shift change note by the oncoming RN and monitored by unit leadership. Unit metrics were collected by the designated unit wound care RN and hospital wound care team. FINDINGS/IMPLICATIONS: To date, a 33% reduction in actual incidence of pressure ulcers combined with a 30% increase in units of service has dramatically reduced our pressure ulcer rate. Focused skin assessment enabled the nurses to intervene before breakdown occurred, and also identified new potential sources of skin breakdown from artificial airway securement devices and positive airway pressure masks. DISCUSSION: Enhanced shift-to-shift bedside rounding with skin assessment has reduced the incidence of pressure ulcers in the ICU. The intervention is now woven into the patient/family-centered care narrative that supports patient safety and comfort during the patient stay in the ICU. Unit nurses are empowered to consult wound care and order specialty beds and other protective products as needed as part of their continuing vigilance for pressure ulcer prevention.

Alvarado K, Lee R, Christoffersen N, Boblin S, Poole N, Lucus J, Forsyth S. Transfer of accountability: transforming shift handover to enhance patient safety. Health Q, 2006;9:75–79.

Hopkins A, Dealey C, Bale S, DeFloor T, Worboys F. Patient stories of living with a pressure ulcer. J Adv Nurs. 2006;56(4):345–353.

Morehead D, Blain B. Driving hospital-acquired pressure ulcers to zero. Crit Care Nurs Clin Am. 2014;26:559–567.

Langemo D, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Adv Skin Wound Care. 2000;13:225–235.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Leslie Everett, BSN, RN, CWON, , Wound Care Center/In-patient, Dallas, TX

Discharging a patient home with negative pressure wound therapy (NPWT) in an acute care facility can be a challenge for the healthcare team. As WOC nurses, we were aware of the issue first hand at our 800-bed acute care inner-city hospital over the past 4 years. The current process for discharging a patient home with NPWT equipment or durable medical equipment (DME) was driven by the WOC nurse because of the clinical data that was required to be entered about the wound on the DME request forms. The current order process had problems such as delays in obtaining an order for the home equipment from the physician, fragmented communication in regard to the delivery of the equipment to the patient, and poor follow-up with the DME company by the requestor via phone calls due to the roaming nature of the WOC nurse in the hospital. A task force was formed to address the current process and our overall goals were to improve patient satisfaction, which meant discharging the patient as soon as possible, which meant having a faster delivery of the NPWT equipment to the patient. The task force met and defined a new process for requesting NPWT DME that was trialed on a busy wound medical/surgical unit with 6 patients. The facilitator now for the request would be the Care Transition Manager for that unit or CTM, with the WOC nurse completing the clinical data required on the request. The new process has resulted in meeting our quality improvement goals of (1) shorter ordering time to delivery of home NPWT equipment to the patient 24 hours prior to discharge usually; (2) improved communication between the care transition managers (CTM) and the WOC nurses; and (3) patient's appear to be satisfied with the new process; no complaints that the discharge was delayed because of no NPWT machine for the patient's home use.

Bryant RA, Nix DP. Acute & Chronic Wounds Current Management Concepts. 3rd ed. St. Louis, MO: Mosby; 2007:579–591.

Wound—Evidence-Based Interventions



Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, , Clinical Education, Austin, TX

BACKGROUND: Published research support for moist wound healing has been available since the 1940s, and in the 1960s researchers provided strong evidence for faster epithelialization rates and decreased infection when wounds were kept moist. Yet, 50 years later, many surgeons worldwide still prefer dry wound management and use toxic antiseptics to prevent infection in open wounds. PURPOSE: The program's goal is to transition hospitals in developing countries to modern moist wound management principles. We wanted to replace antiseptic-and-dry-gauze-dressings with moist, nontoxic materials. We also wanted to emphasize improving nutrition and pain control. APPROACH: Surgeons usually suture the wounds they create, incidentally protecting deeper tissues from desiccation. Dry suture lines give the impression that dry wounds heal well. Diplomatically exposing the fact that this overwhelmingly positive experience with apparent dry wound healing is illusory helped promote changes in attitudes and actions throughout the hospital. Advancing a paradigm shift also facilitated the change: health care professionals do not heal wounds; only the body can heal. We support the body. Moisture facilitates movement of healing and infection-fighting substances across the wound surface. Improved nutrition and pain control further support the body's ability to heal. Other keys to success included:

  1. Laying a strong foundation over time
  2. Avoiding divisiveness by conversing directly with decision makers
  3. Choosing a spokesperson with strong credentials. Experience in a similar setting increased credibility
  4. Coming prepared with solid research evidence
  5. Answering questions respectfully and succinctly
  6. Having realistic expectations—building trust in a new idea takes time

OUTCOMES: The surgical team immediately changed the way they manage wounds to implement moist wound healing principles. Surgeons supported nurses' nutritional teaching and oral pain medications were prescribed earlier to provide more adequate coverage. Almost a year later, many of the changes in wound management have reportedly endured.

Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature. 1963;200(4904):377–378.

Bloom H. Cellophane dressings for second degree burns. Lancet. 1945;246(6375):559. doi:10.1016/S0140-6736(45)91274-8

Bolton L. Operational definition of moist wound healing. J Wound Ostomy Continence Nurs. 2007;34(1):23–29.

Jones VJ. The use of gauze: will it ever change? Int Wound J. 2006;3(2):79–86.

Ovington LG. The evolution of wound management: ancient origins and advances of the past 20 years. Home Healthc Nurs. 2002;20(10):652–656.

Ostomy—Clinical Outcomes



Linda McKenna, MSN, RN, CWOCN, , Wound, Skin and Ostomy Services-Nursing Practice and Innovation, Madison, WI, Vera Allyn B. (Lynette) Scott, RN, BSN, COCN, , Ostomy Services-Nursing Practice and Innovation, Madison, WI, Tracy Schmotzer, MS, RD, CNSC, , Department of Surgery, Madison, WI, and Maria Brenny-Fitzpatrick, MSN, FNP-C, GNP-BC, APNP, , Transitional Care, Madison, WI

BACKGROUND: Fast-track protocols, expectations of early discharge from the hospital and continuous focus on reducing cost have resulted in decreased lengths of stay (LOS) after colorectal surgeries. However, hospital readmission due to complications is an undesirable outcome of an early discharge program. At our 648-bed, Magnet-designated academic center, located in the Midwest, 18.2% of the individuals undergoing colorectal procedures resulting in a diverting loop ileostomy were readmitted within 30 days, many with fluid and nutritional deficits. At our facility, transitional care programs help hospitalized patients transfer in a safe and timely manner to another level of care, such as home or subacute care, yet these programs often focus on individuals with complex medical needs, not postsurgical care.

PURPOSE: Incorporate transitional care into our postoperative colorectal fast track discharge program and better utilize our registered dietitians, so as to decrease readmission rates for individuals with new loop ileostomies. METHODS: In addition to standard pre- and postoperative education, all Fast Track patients with new loop ileostomies receive counseling from our dietitian to aid in preventing dehydration and blockage. All patients are offered enrollment in the transitional care program and receive a notebook, measuring carafe and instructions for recording specific information, such as food intolerances, intake and output, medication usage, signs or symptoms of dehydration, blockage or ileus, and any pouching problems. The transitional care nurse communicates with the patient on a daily basis and relays key information to the health care providers (surgeon, home health nurse, certified ostomy nurse). RESULTS: This collaborative approach has only been utilized for 2 months, but early data indicates a decrease in readmission rates from 18.2% to less than 15%. CONCLUSIONS: Multifaceted programs that target transition of care for individuals with loop ileostomies are successful in decreasing readmission rates.

Hanzlik TP, Tevis SE, Suwanabol PA, Carchman EH, Harms BA, Heise CP, Kennedy GD. Characterizing readmission in ulcerative colitis patients undergoing restorative proctocolectomy. J Gastrointest Surg. 2015;19(3):564–569.

Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, Poritz LS. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55(2):175–180.

Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum. 2012;55(12):1266–1272.

Prinz A, Colwell JC, Cross HH, Mantel J, Perkins J, Walker CA. Discharge planning for a patient with a new ostomy: best practice for clinicians. J Wound Ostomy Continence Nurs. 2015;42(1):79–82.

Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2013;65:471–485.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Lisa Woods, MSN, RN-BC, CWOCN, , Armi Earlam, DNP, MPA, BSN, RN, CWOCN, , and Iris Marshall, RN, BSN, MSN, CWOCN, , Wound, Ostomy and Continence Department, Wheat Ridge, CO; Monica Jarrell, NP-C, DNP, , and Shelley Ruyle, MSN, RN, CAPA, , Ortho/Surgical Unit, Wheat Ridge, CO

BACKGROUND: At our 338-bed acute-care facility, 8 patients with acute hip fracture developed 13 hospital-acquired pressure ulcers (HAPUs) in 2013. Six of the 8 patients who developed HAPUs were admitted to our hospital's 37-bed orthosurgical unit. Pressure ulcers decrease quality of life and increase health care costs. Annually, 60,000 deaths are estimated to be associated with complications from pressure ulcers. In 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs related to HAPUs. METHODS: The purpose of this project was to identify if the implementation of a new evidence-based pressure ulcer prevention protocol that includes (1) hip fracture-specific interventions, and (2) staff education would decrease or eliminate HAPUs for patients receiving care for acute hip fracture. An evidence-based pressure ulcer prevention protocol specific to hip fracture patients was developed and implemented. After an assessment of organizational readiness, facilitators and barriers to change were identified. An evidence-based practice (EBP) team was assembled to address barriers, and included the 3 Wound, Ostomy and Continence (WOC) nurses, the orthopedic nurse practitioner and the orthosurgical unit manager. The WOC nurses provided recommendations to prevent pressure ulcers, educated staff, and consulted on patients, the Orthopedic Nurse Practitioner updated the Hip Fracture PUP Protocol with specific pressure ulcer prevention measures and educated staff, and the manager provided budgetary and administrative support. OUTCOMES AND IMPLICATIONS: Two HAPUs developed in patients admitted with a diagnosis of acute hip fracture in 2014, which represents an 85% decline from the prior year. For 2015, through October, one patient with a diagnosis of acute hip fracture has developed a HAPU. These outcomes support similar targeted pressure ulcer prevention interventions for other high-risk populations. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality, Published 2011. Accessed December 6, 2013. Management of Hip Fracture in Older People. A National Clinical Guideline. Agency for Healthcare Research and Quality. Published 2010. Accessed July 18, 2013.

Haleem S, Heinert G, Parker MJ. Pressure sores and hip fractures. Injury. 2008;39(2):219–223.

Handoll H, Sherrington C, Mak J. Interventions for improving mobility after hip fracture surgery in adults. Cochrane Database System Rev. 2011;(3). doi:10.1002/14651858.CD001704.pub3.

Wound Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Wound, Ostomy, and Continence Nurses Society (WOCN), 96 p. (WOCN clinical practice guideline; no. 2). Published 2010. Accessed July 30, 2013.

Continence—Evidence-Based Treatment and Management



M. Phyllis Green, BSN, RN, CWOCN, , HomeCall, Frederick, MD, Margaret Green, RN, BSN, , Westminster, MD, Kathleen Abramson, RN, BSN, CWOCN, , Damascus, MD, John DiCapo, DPT, , Business Intelligence and Operations, Lafayette, LA, Beth Weldon, PT, , Beltway Division, Lafayette, LA, and Deb Valenza, MBA, , Maryland Region, Baltimore, MD

CLINICAL PROBLEM: Incontinence is a primary reason for leaving one's home. On average, women wait 6½ years to seek help for incontinence. Many patients with incontinence are prematurely placed on medication or referred to the urologist. Home health clinicians have an opportunity to provide continence care in the home which can greatly improve quality of life, reduce fall risk, decrease expenses, and maintain patients at home, yet continence care is often ignored. CLINICAL APPROACH: The continence certified nurse instructed more than 150 staff in nine home health offices on basic continence care. Therapists were taught simple pelvic floor strengthening exercises, not Kegels. Nurses were taught lifestyle interventions, diet, and medication adjustments to improve continence, which were summarized on a 1-page instruction sheet prepared by the continence nurse. Eighteen twice weekly tips were sent to all staff over a 2-month period to explain simple continence care. The home health agency provided patient kits that contained supplies for the exercises and a relaxation CD to calm bladder urges. Patient progress was tracked at the start and finish of the pelvic floor exercises using the Geriatric Self-Efficacy Index for Urinary Incontinence (GSE-UI). OUTCOME: Nurses and therapists noted that the interventions were simple to use. Of the 21 patients tracked, 100% had improved final GSE-UI scores compared to initial scores; the average improvement in 3 to 8 weeks of treatment was 34.14 points, ranging from 11 to 83 points. CONCLUSION: With simple and thorough instruction in continence care, therapists and nurses can work together to provide continence care to home care patients. Pelvic floor exercises can be effective without teaching Kegel exercises. Continence nurses can educate clinicians in continence care, just as is done with wound and ostomy care.

1. Wound, Ostomy, Continence Nurses Society. Reversible causes of urinary incontinence: a guide for patients. Published 2006.

2. Wound, Ostomy, Continence Nurses Society. Role of the WOC nurse or continence care nurse in continence care. Published 2009.

3. Abrams P, Andersson KE, et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse, and Fecal Incontinence. Neurol Urodynam. 2010;29:213–240.

4. Tannenbaum C, Brouillette J, et al. Responsiveness and clinical utility of the geriatric self-efficacy index for urinary incontinence. J Am Geriatr Soc. 2009;57:470–475.

5. Hulme J. Beyond Kegels. 2008.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Malinda Close, RN, BSN, CWOCN, , wound/ostomy, Salem, OR, Kaenta Phothiyane, RN, CCRN, , Cardiovascular Care Unit, Salem, OR, and Ann Alway, MS, RN, CNS, CNRN, , Critical Care, Salem, OR

PURPOSE: To reduce the number of deep sternal wound infections following open heart surgery by half in FY 2014-2015. BACKGROUND: Hospital acquired infections (HAIs) after cardiothoracic surgery continue to challenge nurses working in the cardiovascular care unit (CVCU). Over 20% of HAI cases following open heart surgery are traced to advanced age and obesity. Often the patient's own nasal, oral, or skin flora is the primary source of infection. Four patients in the CVCU developed deep sternal wound infections during the fiscal year 2013-2014. The cost to treat one infection estimated 2.8 times the cost of that for a patient with uncomplicated postoperative course; a routine coronary/artery bypass graft and/or valve replacement range from $50,000 to $200,000. METHODS: In this quality improvement project, physician orders sets were adjusted to include oral chlorhexidine gluconate rinses and intranasal antibiotic ointment; pre- and postoperatively. In addition, a new sternal wound care technique was implemented on high-risk patients. If the patient had reexploration, diabetes, body mass index >30, and/or age >65, then a short-term negative pressure wound therapy (NPWT) system was placed over the closed sternal incision. This system promotes wound healing by promoting blood flow, removing exudate, forming granulation tissue under the incision, and maintain a sterile incision for up to 7 days. RESULTS: Thus far, 382 patients have received open heart procedures with 29 of those having the NPWT applied during FY 2014-2015. Current postoperative infection rate is zero. CONCLUSIONS: Optimizing perioperative order sets and applying a new sternal wound care technique on high-risk patients resulted in no sternal wound infections. Reduction of deep sternal wound infections exceeded our goal to reduce the number by half. The methods above are now part of our order sets for patients undergoing cardiac surgery.

Al-Zaru I, Ammouri A, Al-Hassan M, Amr A. Risk factors for deep sternal wound infections after cardiac surgery in Jordan. J Clin Nurs. 2010;19;1837–1188.

Cimochoswski G, Harostock M, Brown R, Bemardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Presented at the Thirty-Sixth Annual Meeting of The Society of Thoracic Surgeons; January 31–February 2, 2000; Fort Lauderdale, FL.

Grauhan O, Navasardyan A, Hoffmann M, Muller P, Stein J, Hetzer R. Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. J Thoracic Cardiovasc Surg. 2012;9:1–7.

Kollef MH, Sharpless L, Viasnik J, Pasque C, et al. The impact of nosocomial infections on patient outcome following cardiac surgery. Chest J. 1997;112:666–667.

Segers P, Speekerbrink RG, Ubbink DT, et al. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oral pharynx with chlorhexidine gluconate. JAMA, 2006;296:2460–2466.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Marie Brown-Etris, RN, CWON, , Churchville, PA; LaTasha Deer, RN, MSN, MSHCA, CCHP, , Kimberly Daniels, RN, HSA, , and Sharon Bunting-Talarowski, RN, CCHP, , Philadelphia, PA

Correctional medicine, inside the prison, is an untapped area for the WOC nurse. Jails and prisons vary in population numbers, security level (work release to maximum) and availability of medical care. This northeastern USA prison system has a daily census of 7000 to 10,000, yearly intake of 30,000, 6 major housing areas and 5 satellite sites. Twenty years ago they decided to contract for WOC nurse services in order to better manage complex wounds on site which subsequently accelerated transfers into prison, decreased hospital length of stay, decreased transfers to the ED and referrals to outside wound specialists. Hospitalization is also a burden to security. It is typical protocol for one inmate to be shackled in their hospital room and guarded by 2 correctional officers continuously while hospitalized. In our 30-bed Infirmary 4 correctional officers guard all individual rooms and common areas where most inmates can move about freely. From 9/1/12 through 12/31/12, a CQI project was conducted in the prison's Infirmary. 28 patients with a total of 71 wounds were considered for evaluation while 17 patients with 55 wounds meet the criteria of at least 1 follow-up WOC nurse evaluation. Twenty-four wounds (43.65%) healed, 26 (47.35%) improved, and 5 (9%) were unchanged. From 9/1/13 through 1/28/14, a CQI project was conducted in one building's population wound clinic. Twenty-four patients with 68 wounds were included. Of these, 44 (64.7%) healed, 9 (13.2%) improved, and 15 (22.1%) were unchanged of which all required surgical referral which will be discussed in this presentation. No wounds deteriorated in either project. These CQI projects demonstrate the value of the WOC nurse in conducting regular wound rounds in a prison's infirmary and evaluating patients routinely in the wound clinics. Wound etiologies, therapeutic interventions, and implication of wound bioburden will also be discussed as these issues impacted outcomes.

Wound—Management of Complex Wounds



Marine Chan, MSN, CWOCN, , Home Health, Vancouver, BC, Canada

WHAT WAS THE PROBLEM? Every 30 seconds a lower limb is lost due to diabetes mellitus (DM) in the world (www.idf. org/home). 15% patients with DM are at risk for foot ulcers (DFUs); 50% of nontraumatic amputations were related to DFUs; mortality rate of DFU amputations is 50% (Armstrong et al, 2007; Statistic Canada, 2010). Although Total Contact Cast (TCC) is Gold Standard with 90% healing rate, various barriers results in only 2% wound clinics utilized TCC (Fife et al, 2010; Greenagh 2012); lesser effective offloading devices are being used (Bus, 2012; Cavanagh & Bus, 2011; Wu et al, 2008). HOW DID THE AUTHOR(S) SOLVE IT? TCC has straight selection criteria. When TCC is contraindicated, when patient refuses, and/or when deep wound infection is not controlled yet, the author employed TCC Poor Man, the application of a ¼” adhesive felt with a horse-shoe shape hole to offload without immobilize the plantar surface DFU and the periwound skin (Zimmy et al, 2001). WHAT WAS DISCOVERED? The author applied the adhesive felted foam in a way slightly different than Zimmy et al (2001) to address the periwound skin damage related to exudate management. This way of TCC Poor Man application with the use of a ¼” adhesive felt felted foam appeared to be useful to reduce the peak plantar pressures at the site of ulceration. With the application of the TCC Poor Man, patients with plantar DFU have their ulcers closed in weeks. WHAT CAN BE LEARNED FROM THE EXPERIENCE? Effective off-load is critical for healing DFUs. The application of TCC Poor Man is of potential benefit in healing DFUs with Wagner classifications of Class 0 to class 3.

Armstrong, et al. Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286–287.

Birke, et al. Comparison of forefoot ulcer healing using alternative offloading methods.

Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Repair Regen. 2010;18(2):154–158.

Wu Sc, Jensen Jl, Weber AK, Robbinson DE, Armstrong DG. Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach? Diabetes Care. 2008;31:2118–2119.

Zimmy, et al. Effects of felted foam on plantar pressures in the treatment of neuropathic diabetes foot ulcers. Diabetes Care. 2001;24(12):2153–2154

Wound—Preventative Practices New



Martha Taylor, BSN, RN, CWON, , Professional Practice, Ft Lauderdale, FL; Boez Ilderice, MBA, BSHA/HM, RRT, , Andrea MacDonald, AS, RRT, , and Denise Johnston, AS, RRT, , Respiratory Dept, Ft Lauderdale, FL

This was a collaborative approach to solving a very plaguing problem of our ICU patients. We had experienced 18 SDTI/full-thickness injuries of the nasal bridge due to Bi-pap use in 2014. This was an unacceptable occurrence rate in a zero tolerance environment. Respiratory department and nursing had to come together to problem solve and identify opportunities for change in the process of Bi-pap usage. Points along the process were identified including education, equipment, skin care, responsibility, and timing of care. It took another 6 months to educate, assess, introduce new equipment, and fine tune the process that was going to get us to zero skin breakdown. Since the new processes have been put into place, we have not had a pressure ulcer of the nasal bridge.

1. National Pressure Ulcer Advisory Panel. Best practices for prevention of medial device-related pressure ulcers.

2. Black JM, Cuddigan JE, Walko MA, et al. Medical device-related pressure ulcers in hospitalized patients. Int Wound J. 2010;7(5):358–365.

3. Visscher M, King A, Nie AM, et al. A quality-improvement collaborative project to reduce pressure ulcers in the PICUs. Pediatrics. 2013;131(6):e1950–e1960.

4. Lemyze M, Mallat J, Nigeon O, et al. Rescue therapy by switching to total face mask after failure of face mask-delivered noninvasive ventilation in do-not-intubate patients in acute respiratory failure. Crit Care Med. 2013;41(2):481–488.

Ostomy—Clinical Outcomes



Mary Willis, MS, RN, CWOCN, , Diane Bryant, RN, MS, CWOCN, , Ilene Fleischer, MS, RN, CWOCN, , Nancy Foley Barry, BSN, RN, , Elizabeth Doane, MSN, RN, ACNS-BC, , Maria Maglio, BSN, RN, , Ann Furey, MSN, MBA, RN, , Jeanne Praetsch, MS, RN, CCRN, and Sarah Thompson, MSN, RN, CCNS, CWON, , Nursing, Boston, MA; Jennifer Beatty, MS, PA-C, , and Joy Brettler, BS, PA-C, , Surgery, Boston, MA; Amanda Eberstadt, MS, RD, LDN, , Sara McGowan, MS, RD, LDN, , and Erin Sisk, MS, RD, CNSD, , Nutrition, Boston, MA; Pamela Fine, BA, , Care Coordination, Boston, MA

An analysis of colorectal readmissions revealed that dehydration was a frequent cause of readmission after major colorectal surgery. Patients who had an ileostomy creation were at the greatest risk. Our objective was to reduce readmissions due to dehydration by 50%. METHOD: An interprofessional Colorectal Quality Improvement Team was established to reduce readmissions due to dehydration. This group met twice per month. The participants represented clinicians from across the continuum of care and uncovered many inconsistencies and gaps in patient education. One area of focus was teaching patients how to measure fluid intake and stool output at home after discharge. A daily work sheet to track this activity was developed. Patients were taught specific interventions to follow based upon the data collected. Education was provided before surgery by the certified wound and ostomy care nurses at the preoperative appointment. The education was reinforced throughout the inpatient stay by the bedside nurse, clinical educator, and the visiting nurse at the patient's home. Hospital readmissions were followed and data tracked. RESULTS: Since implementation of the education program, 1 patient was seen in the emergency department and only 1 patient needed to be admitted to the hospital. CONCLUSIONS: Consistent patient education across the continuum of care has been successful in decreasing readmissions related to dehydration. CLINICAL IMPLICATIONS: Consistent patient education from the preoperative visit, during the inpatient stay, and reinforced at home has been shown to reduce hospital readmissions due to dehydration. Decreasing readmissions improves the patient experience as well as decreases healthcare costs.

Messaris E, Sehgal R, Deiling S, Koltun WA, Stewart D, McKenna K, Poritz LS. Dehydration is the most common indication for readmission after diverting ileostomy creation. Dis Colon Rectum. 2012;55(2):175–180.

Continence—Complications of Incontinence: Dermatological Issues; Urinary Tract Infection; Renal Deterioration



Shelley Lancaster, MSN, ACNS-BC, CWOCN, , and Jane Forni, MSN, RN, , Nursing Administration, Avon, IN; Deborah Kleissler, RN, CWOCN, , IU Health West Hospital, Avon, IN; May Ishikawa, BSN, CWOCN, , MedSurg/ICU, Avon, IN

Catheter-related urinary tract infection (CAUTI) is one of the most frequent hospital-acquired infections. It is known that following the bundle of best practices can lead to a reduction in CAUTI. Our critical care unit had already aggressively implemented this bundle of care and participated in a LEAN Rapid Improvement Event, reducing CAUTI by over 40%, and were still experiencing patients with CAUTI. We wanted to do more. After consultation with an antibiotic stewardship expert and collaborating with our Infection Prevention Committee colleagues, we implemented a novel prophylaxis regimen using Clorpactin bladder irrigations, starting Foley Catheter day 4, repeating every 3 days until the catheter was removed. Clorpactin (Oxychlorosene in 0.9% sodium chloride, final concentration 0.05%) is a topical irrigant antiseptic and works via oxidation and chlorinization of cell proteins and enzymes. This product has been available since the 1950s, costs little to use, and is well-tolerated in the literature. After implementing the Clorpactin bladder irrigation prophylaxis protocol in January of 2014, our 16-bed ICU/PCU went from 6 CAUTIs in 2013 to one CAUTI in 2014, an 83% reduction. Our CAUTI rate per 1000 Foley days reduced from 3.4 in 2013 to 1.31 in 2014. We are currently at zero in our ICU for the first 9 months of 2015. It appears that this practice is making a difference for our patients. We will present 2 complete years of data from our ICU. The financial impact at our small hospital of going from 6 to 0 CAUTI annually is approximately a $6,000 savings. However, the estimated total cost of CAUTI annually in the U.S. is $450 million. If further research supports this inexpensive (less than $1.00 for the irrigation solution) intervention the financial impact would be substantial.

Wound—Evidence-Based Interventions



Mei Yu Hsu, , and Hui Chun Chung, , Department of Nursing, Hualien; Ji Yan Lyu, , Hualien; Hsiao Hui Hsu, , Buddhist Tzu Chi General Hospital, Hualien

BACKGROUND: Radiation dermatitis (RD) are relatively frequent skin side effect during treatment of head and neck cancer (HNC) with radiotherapy (RT). The effects of severe RD may require interruption in or cessation of treatment, and also impact on the quality of a patient's life causing by pain, discomfort, and limit activities. OBJECTIVE: This innovation project was to identify the evidence-based interventions for RD. Creating and implementing a bundle of care and measuring the effects on the incorrect rate of patient self-care and the incidence of severe RD. METHODS: This project was carried out between May 2013 and December 2013 at medical center. The team comprised 5 advanced practice nurses and 2 doctors with expertise in the field of wound, oncology, and radiology. First, through a structured evidence-based review process to create a care bundle, consisting of 6 elements of care. Second, the incidence of severe RD and the incorrect rate of patient self-care were compared before and after implementation of a care bundle. RESULTS: A total of 23 HNC patients were treated with RT. The median age of the patients was 69 years, and 82% were male. The incidence of severe RD decreased from 25% to 10%. The incorrect rate of patient self-care reduced significantly from an average of 63% to 16.7%. CONCLUSION: This implementation of an RD care bundle was associated with decreased incidence of severe radiation dermatitis in head and neck cancer patients undergoing RT and it showed a positive impact on patient skin self-care.

Bolderston A, Lloyd NS, Wong RKS, Holden L, Robb-Blenderman L. The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline. Support Care Cancer. 2006;14(8):802–817.

Kedge EM. A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients. Radiography. 2009;15(3):247–257.

Kumar S, Juresic E, Barton M, Shafiq J. Management of skin toxicity during radiation therapy: a review of the evidence. J Med Imaging Radiat Oncol. 2010;54(3):264–279.

Lambertz CK, Gruell J, Robenstein V, Mueller-Funaiole V, Cummings K, Knapp V.). NO SToPS: reducing treatment breaks during chemoradiation for head and neck cancer. Clin J Oncol Nurs. 2010;14(5):585–593.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Melayne Martin, BSN, RN, CWOCN, , Parkland Health & Hospital System, Dallas, TX; Swann Waterhouse, BSN, RN, WCC, , Wound Care, Dallas, TX; Donna Richardson, DNP, RN, NEA-BC, , and Jacqueline Sullivan, PhD, RN, , Dallas, TX

Patient Safety Indicator 3 protects the patient from harm. It drives quality care and prevents hospital-acquired pressure ulcers (HAPUs) whose development has been identified as a sign of poor care. In an effort to ensure that quality care is being provided and patients are protected, institutions are surveying more often and being held more accountable than ever. Failure to recognize unavoidable skin injury related to end of life both clinically and in the regulatory forum has tipped the scale for institutions responding to this challenge. One urban safety net hospital decided to examine this impact. Two years of data that included 129 cases were reviewed via electronic and coding records to match qualifications for Kennedy Terminal Ulcer (KTU) and/or Skin Changes at Life's End (SCALE). Patients qualified for KTU when a sacral wound had the correct shape progressed rapidly to necrosis and the patient died within 6 weeks. Patients qualified for SCALE when they died within 1 year of developing a sacral wound, and experienced sustained hypotension, hypoxia, and Multisystem Organ Failure (MOF/MODS) when the ulcer declared. Of our 129 reported HAPU cases, 34 or 26% died. Of these, 35% met KTU criterion and 23% met SCALE criterion. A total of 12.4% of our reportable pressure ulcers were evidence of the progression of the disease process and therefore not negligence. Zero harm remains the ideal and the mission in our institution from the board room to the patient room. In these 34 cases, the best practice interventions were implemented and the ulcer was a symptom of failure of the patient, not the care. Increasing unavoidable skin injury awareness will help drive regulatory bodies, bring back balance, and protect both patients and institutions.

Chrisman C. Care of chronic wounds in palliative care and end-of-life patients. Int Wound J. 2010;7:214–235.

Edsberg L, Langemo D, Baharestani M, Posthauer ME, Goldberg M. Unavoidable pressure injury state of the science and consensus outcomes. J Wound Ostomy Continence Nurs. 2014;41(4):313–334.

Langemo DK, Brown G. Skin fails too: acute, chronic and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206–211.

Lepak V. Avoidable & inevitable? Skin failure: The Kennedy Terminal Lesion. J Legal Nurse Consult. 2012; 23(1):24–27.

White-Chu E, Langemo D. Skin failure: identifying and managing an underrecognized condition. Ann Long-Term Care. 2012:20(7).

Professional Practice—Computer Software Applications: Database Programs; Statistical Packages; Educational Resources



Michael Kalos, BSN, RN, CWOCN, , Education, Hugo, MN; Krista Kipper, MSN, RN, CHSE, , and Trent Kroschel, BSN, RN, , HealthPartners Clinical Simulation, St. Paul, MN

Pressure ulcer prevention has become a very important paradigm for the healthcare industry. Since 2008, when CMS no longer reimbursed hospital-acquired pressure related injuries, Hospitals and Healthcare systems have tried to find ways to reduce the number of incidences within their walls. In 2015, several key proposals were developed within this 400+-bed Level I Trauma Center to address safe skin mandates for pressure ulcer-reducing strategies. One such strategy was an educational initiative to demonstrate proper repositioning of patients. An innovative multimedia approach was created to deliver the message using a video format. The CWOCN consult services, with the help of the organization's Clinical Simulation team, developed the clinical content for proper repositioning and created a fun and educational video. This medium used an early form of movie style: silent filmography. The content was presented without sound and in black and white. The scene starts with the patient in an average hospital room and bed—having slid down into the “crease.” The RN arrives and offers to assist with repositioning. The screen fades to a title card narrating the interactions. The return to action shows the RN encouraging the patient to turn and then placing pillows for comfort. All the time background music is played to an upbeat piano melody. The video ends after a few more title cards and scenes with the actors giving the “thumbs up” salute. This innovative educational approach developed by the CWOCN consult services and clinical simulation team to convey tried and true methods of positioning has been positively received. The video will be presented at all new hire orientations, skin, and wound resource nurse program classes and as needed resource for unit managers.

Continence—Issues in Bladder and Bowel Continence Management



Misty Stephens, ETN (C), , Surgical Acute Care, Burnaby, BC, and Lisa Hegler, CWOCN, , Medicine Acute Care, Burnaby, BC

BACKGROUND: Continence management for adults in acute care experiencing transient or persistent urinary and/or fecal incontinence is essential to prevent incontinence-associated dermatitis, lower urinary tract, and skin infections and pressure ulcers. Unfortunately, the overuse of briefs in acute care patients increases functional incontinence, the risk of infection, and epidermal damage. This occurs when the occlusive environment traps heat, enzymes and moisture allowing microbes to flourish causing skin to become more vulnerable. When incontinence is managed with best practice principles/initiatives, this decreases the incidence of care-sensitive adverse events (CSAE) such as pressure ulcers, falls and hospital acquired urinary tract infection (HAUTI), functional incontinence, and epidermal damage and infection. PURPOSE: Develop and implement a continence protocol for adults in acute care in a large community-based hospital in western Canada. METHOD: A multidisciplinary team, including CWOCN, ETN (C), NCA, Professional Practice, PT, OT, unit managers and hospital directors, developed an evidence informed continence management protocol. The protocol includes algorithms such as scheduled toileting, collection devices, and 2-piece containment devices. Briefs are not ward stock. Briefs are only an option once everything else has been tried and failed and a CWOCN/ETN (C) referral has been made for assessment for a brief. Staff education about the protocol/algorithm and products were provided for 6 weeks prior to the implementation of the new protocol and products. OUTCOMES: Scheduled toileting was initiated into patient care plans. Incidence of pressure ulcers has dropped from 62% (2009) to 4% (2015). Care-sensitive adverse events for urinary tract infections are decreasing. The reduction of CWOCN/ETN(C) referrals for incontinence-associated dermatitis went from 68 (85%) to 3 (0.03%) in 4 months.

Beekman D, et al. Proceedings of the Global IAD Expert Panel. Incontinence associated dermatitis: moving prevention forward. Wounds Int. 2015.

Doughty D. Urinary and Fecal Incontinence Nursing Management. 2nd ed. 2000.

Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans K, Palmer MH. J Wound Ostomy Continence Nurs. 2007;34(1):45–54.

Registered Nurses Association of Ontario. Nursing Best practice guideline: promoting continence using prompted voiding. Published 2011.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Naoko Otsuji-Miwa, RN, BSN, CRRN, CWOCN, CFCN, , Wound care department, Philadelphia, PA and Evelyn Phillips, MS, RDN, CDE, , Clinical Nutrition, Philadelphia, PA

PURPOSE: Malnutrition can increase the risk of skin breakdown and impair wound healing. Early assessment of patients' nutritional status is crucial for predicting and preventing skin breakdown and/or further wounding, especially given the high acuity level of our acute rehabilitation (AR) patients. Laboratory values such as albumin and prealbumin are now known to be altered by inflammation and are not valid in assessing for malnutrition in patients with recent inflammatory triggers (acute disease/injury). Patients' transfer records do not always provide information on the patient's nutrition status or skin condition. A recent 2-month study found 50% of our patients had malnutrition and 51% of these patients had pressure ulcer (PrU) assessed by the RD and WOC nurse on admission. This joint assessment facilitates more accurate determination of patient's nutritional needs and prediction of the course of wound healing and risk of skin breakdown. OBJECTIVE: To illustrate how sharing office space promotes collaboration between the RD and WOC nurse and how early identification of malnutrition is crucial for accurate PrU risk assessment and intervention. METHOD: RDs and WOC nurses exchange patients' information during the joint assessment and daily basis. We will present dialogs and benefits of our discussion in the “room together” from our experiences. DISCUSSION: The estimated cost to heal a PrU ranges from $3500 to $60,000 with litigation costs ranging into the millions. In our 96-bed AR hospital, we have 3 WOC nurses and 3 RDs who share an office. This higher than typical RD and WOC nursing staffing levels can be justified by the avoidance of a single hospital-acquired PrU. The room together aides in reducing costs by enhancing staff performance and efficiency. CONCLUSION: We recommend a shared wound-nutrition office to facilitate accurate PrU risk assessment and early intervention, reducing costs and improving patient outcomes.

Cox J, Rasmussen L. Enteral nutrition in the prevention and treatment of pressure ulcers in adult critical care patients. Crit Care Nurs. 2014;34(6):15–28.

Johnston E. The role of nutrition in tissue viability. Wound Essent. 2007;2:10–21.

Coiera E. Communication system in healthcare. Clin Biochem Rev. 2006;27(2):89–98.

Thompson C, Furhrman P. Nutrients and wound healing: still searching for the magic bullet. Nutr Clin Pract. 2005;20(3):331–347.

Antokal S, Garcia A. Pressure ulcer prevention in vulnerable elders. NPUAP Webinar. 2015 October.

Ostomy—Psychosocial and Quality of Life Aspects



Nora Sammon, CWOCN, , Medical Surgical Nursing, New York, NY

Children with ostomies are especially vulnerable and may have difficulty transitioning from hospital to home. Providing patients and families with age-specific materials will help the pediatric patient relate to what they're learning while providing them with the confidence and knowledge needed to participate in childhood/adolescent activities. Today, the majority of ostomy education available centers on the adult population and often does not include a pediatric focus. A few ostomy manufacturers have created coloring books and dolls to assist toddlers to pre-school-aged children; however, the choices are limited. The development of the pediatric lifespan is critical and having supportive materials can provide the patient with the security needed to develop a healthy outlook and relationships with their peers. When a child receives an ostomy, their childhood is impacted by their ostomy surgery. Having age-appropriate materials available will increase their confidence, diminish their fears, and assist the parents and child in adapting to a new normal. Each stage of childhood and adolescence has specific needs in order to learn how to manage and accept their ostomy and being able to tailor pediatric education will address specific needs for that age group. More options for learning materials will increase the bond between the parent and child and child and WOC nurse. The development of new educational tools, including books, pamphlets, and technology, required collaboration with parents, WOC nurses, child life specialists, illustrators, and designers. The outcomes of these innovative tools are improved adaptation and increased confidence for the pediatric patient.

Barreto LCL, Cardoso MHC, Villar MAM, Gilbert ACB. Professional health care team perception as to ostomized children discharge in a pediatric hospital unit. Revista Gaucha de Enfermagem, 2008;29(3):438–445.

Bennett Y. Understanding the challenges and management of paediatric stomas. Gastrointestinal Nurs. 2010;8(7):38–42.

Doughty D. Complex ostomy care: paediatric stomas, high output stomas and difficult pouching situations. World Council Enterostomal Therap J. 2006;26(3):26–31.

Forest-Lalande L. Clinical corner: ostomies in childhood: psychosocial repercussions. Link 2004:17012473. ISSN: 1701-2473. 10-17.

Zarroug AE, Stavlo P, Moir CR. Pediatric colon surgery: challenges, functional outcome and quality of life. Colon Rectal Surg. 2006;17:43–48.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Pamela Messer, BSN, RN, , Inpatient Wound Care, Ashland, KY

PURPOSE: Drill down on assessments, moisture, compliance, resources, and empowering staff to reduce hospital-acquired buttock and sacral pressure ulcers (HAPU) in a 12-bed intensive care unit. OBJECTIVE/SIGNIFICANCE: Critical care patients are at higher risk for developing HAPU because of hemodynamic instability, comorbidities, devices, and vasopressors. Bundling evidence-based practices (EBP) has shown to improve patient outcomes. Gaps existed with bundling and charting. Problems with moisture, shear, and friction continued. Objective was to develop a strategy to sustain a bundled EBP and reduce overall HAPU by 25% for the year and zero buttocks and sacral HAPU for 30 days. STRATEGY/IMPLEMENTATION: Current resources: 5-layer silicone sacral adhesive foam, lift team, heel suspension boots, barrier cloths, and creams. New resources: 30-day trial of absorbent under pads; eliminated blue quilted under pads, diapers, and Chux; emphasis on barrier cloths and foam cleanser instead of washcloths and liquid soap. Wound care nurse: development of a bundled checklist; 1:1 return demonstration education for risk assessment and charting; chart audits; compliance graphs; safety calendar, biweekly rounding. Practice changes: risk assessment every shift and dual registered nurse skin assessments at admission and transfer. EDUCATION: product representatives and lift team refresher course. RESULTS: No hospital-acquired shear, friction, dermatitis, or pressure ulcer development in 74 patients. The skin champions and staff became the gatekeepers for the PUPP. After 1 year, we saw a HAPU reduction of 67% and compliance averaged 95%. CONCLUSION: We extended the practice in the hospital with additional resources: ear protectors, chair cushions, absorbent pull-ups, skin champions, education added to orientation, and purchased a low air loss with microclimate management surface. With a customized EBP checklist and buy-in from staff, education, increased compliance, and additional resources to bundle our approach; we were able to decrease our HAPU by 57% hospital wide.

Cooper KL Evidence-based prevention of pressure ulcers in the intensive care unit. Crit Care Nurse. 2013;33(6):57–66. doi: 10.4037/ccn2013985.

Downie F, Perrin A, Keirnan M. Implementing a pressure ulcer prevention bundle into practice. Br J Nurs. 2013;22(15):S4–S10. doi:10.129681bjon.2013.22Sup10.54.

Institute for Healthcare Improvement. How to guide: prevent pressure ulcers. Published 2011.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Park, Western Australia: Cambridge Media; 2014.

Ratliff RR, Tomaselli N. Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Patricia Hayes, MSN, RN, CWCN, , and Parese Fasciocco, BSN, RN, CWOCN, , Nursing Education and Professional Development, Philadelphia, PA

Assessment and documentation are key elements to ensure reimbursement for patients admitted with pressure ulcers. It is important that all nurses receive consistent education on caring for the patient who is at risk or presenting with a pressure ulcer. In 2013, the wound care specialists at an accredited Level 1 Regional Resource Trauma Center in an urban community assessed the need to develop a comprehensive process for the professional bedside nursing staff which included pressure ulcer prevention, identification, assessment, documentation, and topical management. Comprehensive nursing education included a monthly newsletter, development of evidence-based nurse-driven interdisciplinary plans of care for pressure ulcer prevention and management, 8-hour PSNA-approved wound and ostomy class and initiation of a skin defense committee. Annual pressure ulcer competency for registered nurses was conducted over a 3-year period, which included assessment and computer documentation of a pressure ulcer. First-time pass rate of the competency increased during this time frame. While there was an established increase, consistent errors were noted. Modification of the computer documentation system for pressure ulcers was an identified need.

Wound—Preventative Practices New



Rachel Donovan, BSN, RN, CWOCN, CFCN, , and Paula Schindler, BSN, RN, CWOCN, , Wound Ostomy Department, Covington, LA

The incidence of hospital-acquired pressure ulcers (HAPUs) plateaued at a rate of 7.8% in 2 critical care units despite a prevention bundle, which included risk and skin assessment, moisture management, and offloading. Additionally, respiratory medical device-related pressure ulcers notably increased to 3.7%. At a facility expense ranging from $500 to $70,000 per pressure ulcer, an incidence of 2 per month could cost the hospital a maximum of $1.68 million annually. Through a collaborative approach, the aim of this quality improvement project was to determine if utilizing prophylactic silicone foam dressings would reduce the incidence of pressure ulcer development, hence result in cost savings for the facility. An interdisciplinary team of WOC nurses, critical care nurses, and respiratory therapists utilized the plan-do-check-act quality improvement cycle. Clinical parameters for inclusion as high risk, requiring prophylactic dressings were: Braden score of 13 or less, vasopressor, high flow nasal cannula, noninvasive ventilation, tracheostomy, localized tissue edema, immobility, and previous pressure ulcer. The team was educated on correct scoring of the Braden scale, the impact of vasopressor medications on pressure ulcer development, dressing application and mode of action related to prevention. Patients were assessed using an info graphic developed by the team that contained inclusion criteria and dressing selection. Data was gathered using pressure ulcer incidence per one thousand patient days for 6 months. Prophylactic silicone foam dressings to the sacrum, heel, and under respiratory medical devices as an adjunct to the current pressure ulcer prevention (PUP) bundle yielded a zero incidence rate, resulting in a potential cost savings of $840,000 biannually. Recommendation for modification of the PUP protocol was submitted to, and accepted by, Shared Governance Councils, inclusive of algorithm for utilization of prophylactic silicone foam dressings, specific interdisciplinary roles, annual competency training, and revision of clinical documentation to reflect recommended interventions.

Black JM, Cuddigan JE, Walko MA, Didier LA, Lander MJ, Kelpe MR. Medical device related pressure ulcers in hospitalized patients. Int Wound J. 2010;7:358–365.

Cox J. Predicators of pressure ulcers in adult critical care patients. Am J Crit Care. 2011;20(5).

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014.

Padula W, Mishra M, Mackic M, Sullivan P. Improving the quality of pressure ulcer care with prevention. Med Care. 2011;49(4).

Santamaria N, Gerdtz M, Sage S, et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. Int Wound J. June 2013;12(3):302–308. Retrieved from Epub 2013 May 27.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Raywatee Lal, RN-BSN, , Nursing, Brooklyn, NY

PURPOSE: The purpose of this nurse-driven skin saver quality improvement project is implementation of process mapping to (1) improve pressure ulcer (PrU) documentation, (2) increase awareness of PrU prevention best practices, and (3) reduce the incidence of unit-acquired PrUs during quarterly surveys. OBJECTIVES: After viewing this poster, the learner will be able to: • Define what is a skin saver resource leader; • Verbalize the 6 steps of Larrabee's model for evidence-based practice change; • State why the need for change in practice. CONCEPTUAL MODEL: Larrabee's (2007) model for evidence-based practice change. SUBJECTS AND SETTING: A cohort of 34 registered nurses on 33-bed medical-surgical unit in 212-bed community hospital. METHODS: Biweekly nurse-to-nurse wound and skin rounds conducted by skin saver resource leader with consultation from wound nurse practitioner as needed. Immediate feedback provided to nurse on condition of wound and plan of care adjustments. OUTCOMES: • For 12 consecutive quarterly prevalence surveys from 2012 to 2015 (4 years), there were no unit-acquired pressure ulcers. • Skin tears and moisture-associated skin damage (MASD) were not documented in error as PrUs.

Agency for healthcare Quality and Research. (2000). Preventing pressure ulcers in hospitals.

Braden B, Bergstrom N. Braden Scale for predicting pressure sore risk. Published 1988.

Haag-Heltman B, George V. Nursing peer review: principles and practice. Am Nurse Today. September 2011;6(9):49–52.

Larrabee JH. Nurse to Nurse: Evidence-Based Practice. New York, NY: McGraw-Hill; 2009.

National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2010.



Richard Schneider, MBA, RN, CWON, , Wound Ostomy Care Team, Charlottesville, VA, and Carolyn Ramwell, MSN, CPNP, , Nursing Education, Charlottesville, VA

TOPIC: Each week over 1400 lower limbs are amputated on adult diabetics. Remote Area Medical (RAM) clinics are often the only opportunity for comprehensive preventative health care for the people of Appalachia. A team of WOC nurses partnering with a pharmacist provided rural underserved patients with comprehensive diabetes foot care. PURPOSE: To provide comprehensive interventional diabetic foot care, education, and supplies to a remote and underserved population in rural Virginia. OBJECTIVES: This innovative program included specialized diabetic foot assessments and interventions. Care included ABI measurements, x-rays, orthotic fittings, and diabetic socks with referral to a roving community health van for follow-up. The program had a 3-fold purpose: First, that comprehensive diabetic foot care would be provided. Second, teach back-education on 3 specific points of importance of diabetic foot care were taught pretreatment and posttreatment patients were evaluated by requested teach back for retention and comprehension of foot care. Third, that follow-up appointments would be scheduled when possible by local free community clinic staff with the uninsured, rural, and transient population treated at remote RAM clinic. OUTCOMES: Fifty-four patients were treated in 2 days: All patients had toenails trimmed and callouses removed. One patient with a chronic wound was treated. 23% of patients had tinea pedis, and 39% had onychomycosis. All patients received 3 point education, and all patients were able to independently demonstrate back 1 of 3 points. All received supplies ranging from topical ointments, to diabetic socks and diabetic shoes. In addition, 3 nondiabetic patients with Charcot foot were identified, x-rayed, and treated. All patients that lived within driving distance were scheduled follow-up appointments with a NP at a community free clinic. Through the RAM clinic underserved patients received needed comprehensive foot care.

Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. 2012.

Wound—Preventative Practices New



Richard Schneider, MBA, RN, CWON, , Wound Ostomy Care Team, Charlottesville, VA, Dea Mahanes, MSN CCRN CCNS, , Neuro ICU, Charlottesville, VA, Kristi Wilkins, MSN CCRN CCNS, , Surgical Trauma Burn ICU, Charlottesville, VA, and Ashley Bruce, RRT-ACCS, , Surgical Trauma Burn ICU and Neuro ICU, Charlottesville, VA

WOC nurses have a key role in collaborating to reduce device-related pressure ulcers. Patients are at risk for device-related pressure ulcers following initial percutaneous tracheostomy placement, specifically breakdown under the bottom edge of the flange. A WOC nurse, together with respiratory therapy, nursing, and physicians from two ICUs, evaluated practice and developed prevention strategies. The WOC nurse provided consultative recommendations on dressings that could assist a modified suturing technique and added the use of a hydrocolloid dressing to protect the skin under the flange from friction and shearing until the sutures where removed and standard trach care could be initiated. The 2 ICU units shared RT, WOC nurse, and LIP personnel, supporting rapid implementation within 1 week of the index case. Initial resistance to change was successfully addressed by emphasizing that the practice was being “tested” with further refinement to be based on comments from staff. With minor revisions, this standard practice has now been utilized in 71 cases. In the 5 months prior to this intervention, review of quality data revealed an average of 1 to 2 tracheostomy-related pressure ulcers per month between the 2 units. In the 11 months since standard practice implementation, there have been no reports of skin breakdown. Of importance, there have also been no reports of complications (for example, tracheostomy dislodgement) related to the new technique. Future refinement of the standard practice includes emphasis on special populations such as patients with copious peristomal secretions and the burn population.

Apold J, Rydrych D. Preventing device-related pressure ulcers: using data to guide statewide change. J Nurs Care Qual. 2012;27:28–34.

Boesch RP, Myers C, Garrett T, et al. Prevention of tracheostomy-related pressure ulcers in children. Pediatrics. 2012;129:792–797.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Rose Raizman, RN-EC, MSc, MNurs, CETN(C), , Toronto, ON, Canada

OBJECTIVES: This project was conducted in the multisite community hospital to evaluate new bathing product against currently used method which is face cloth, soap, and water in the basin. METHOD: Sixty-one respondents consisting of 36 patients and 25 caregivers from surgical, medical, postacute, rehab, and cardiac floors were bathed using a new bathing product. Patients and caregivers (nurses and support workers) were asked to fill in a questionnaire and compare experience to the previous bathing experience. Likert-type scale was used to collect subjective information and comments compiled to get common themes. Evaluations asked basic demographic data, comfort level after bathing experience, comparison to previous bathing experience for the patients and ease of use for nurses along with other relevant data. RESULTS: There were 28 male and 33 women in the study. Average age was 73.2. Emerging theme among patients was “real suds—real bath,” “easy to use and feels clean.” Patients or caregivers were strongly agreeing with the statement indicating preference of the evaluated products. Patients were more inclined to strongly agree with preference of evaluated product than nurses. Detailed responses are presented in the graphs. CONCLUSIONS: Even though comfort of the shower is the preferred method of bathing for most patients, bath in the bag was found to be cost neutral and superior in comfort and experience. Strong preference of the product to the water basin and soap was found. The evaluation process also helped caregivers to understand the importance of the bathing experience in the therapeutic relationships. In the future comparison of rates of hospital-acquired infections among patients bathed with self-sudsing washcloths and washcloths with soap and basin should be performed.

1. Larson EL, Ciliberti T, Chantler C, Abraham J, Lazaro EM, Venturanza M, Pancholi P. 2004 Comparison of traditional and disposable bed baths in critically ill patients. Am J Crit Care.

2. Johnson D, Lineweaver L, Maze LM. Bath basins as potential sources of infection: a multicenter sampling study. Am J Crit Care. 2009;18:31–40.

3. Clark A. Nosocomial infections and bath water: any cause for concern? Clin Nurs Spec. 2006;20(3):119–123.

Wound—Product Selection and Innovations



Ruth Iliuta, CWON, , GEC, Perryville, MD

BACKGROUND/SIGNIFICANCE: Due to the increasing costs of renting specialty mattresses for pressure ulcer (PU) prevention and treatment, a quality improvement project was initiated to determine if purchasing specialty mattresses (alternating pressure) would reduce the number of facility acquired pressure ulcers (FAPU) and result in cost savings. METHODS: In October 2013, the cost for renting mattress/bedframes for PU prevention/treatment (92 totals) was $37,875/month for a 155-bed Community Living Center (CLC). It was determined that the cost and usage of specialty mattresses could be managed by replacing rental products with facility owned items. This would allow each resident to be placed on a pressure redistribution mattress upon admission or when their conditions changed, and prevent a delay in care. Staff from nursing, biomedical and engineering, environmental management and acquisitions and management participated in a “Bed Fair” to evaluate the products. The product chosen not only supported PU prevention but could accommodate taller and bariatric residents, assist with fall prevention, and reduce staff injuries. The purchase, delivery, and setup process was completed by April 2014. RESULTS OR OUTCOMES: In 2013, the number of FAPU in the sacral/torso area was 17. For 2014 the number of FAPU in these same areas numbered 9. These results have been sustained through September of 2015 with only 3 FAPU. The cost of the purchase is completed over 24 months, with the future being “cost neutral.” CONCLUSION/RECOMMENDATIONS: While no single product alone can reduce PUs, as part of a total program, specialty surfaces do play a significant role. The cost savings with purchase over renting is significant. This new process engages and empowers the nursing staff to match the product to the resident at the time of need.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth, Australia: Cambridge Media; 2014. Accessed November 4, 2015.



Samantha Westgate, , Hannah Thomas, , and Rebecca Booth, , Cheshire; Jodie Lovett, MEng, , and Christian Stephenson, BSc, , Research and Development, Knutsford

INTRODUCTION: The presence of methicillin-resistant Staphylococcus aureus (MRSA) within chronic wounds poses a risk to the patient and surrounding patients/caregivers. Sequestration of MRSA in a dressing would improve the infection status of the wound bed and decrease the risk of MRSA transmission. This study looks at MRSA sequestration of foam dressings following absorption. METHODS: Six different foam dressings were assessed over 7 days compared to knotted gauze. Dressings (n = 12) were placed on 15 mL of MRSA inoculum containing 106 cfuml−1. 15 mL of inoculum was added daily for 7 days in order to mimic a highly exuding wound. On days 1, 3, and 7 dressings were transferred to agar plates and incubated overnight at 37°C. Dressings were then removed from the agar plates and photographed for evidence of MRSA transfer from the dressing. Samples of the inner material of each dressing were processed and remaining viable bacteria quantified. Additional samples of the inner core were fixed and visualized using Environmental Scanning Electron Microscopy (ESEM). RESULTS & DISCUSSION: All dressings except the gauze control absorbed the 15-mL MRSA inoculum supplied each day. Five of the 7 dressings demonstrated comparable MRSA recovery to the gauze control. A 3 log increase in MRSA retention was observed Foam F compared to the other dressings tested. Upon transfer to agar, 4 of the foam dressings demonstrated improved retention over 7 days. The remaining 3 and gauze released MRSA onto the agar throughout the study. In the ESEM microscopy, MRSA was observed within the inner core of Foam F. This contrasted with the other tested dressings which had MRSA on the outer layer. CONCLUSION: Retention of MRSA through the recovery steps suggested that the inner core sequestered microorganisms as bacteria were not readily released. MRSA not released was assumed to be held within the foam technology.



Sarah Roberts, MPharmSci, , David Warde, PhD, , Jodie Lovett, MEng, and Christian Stephenson, BSc, , Research and Development, Knutsford

INTRODUCTION: It is widely recognized that pressure ulcers are caused by a number of factors including pressure, shear, and microclimate.1 The aim of this study was to assess 4 foam dressings* for pressure and shear redistribution, and skin surface microclimate control. METHODS: Pressure and shear forces were measured when a standard weight was applied to a pressure-sensitive mat. A dressing was then applied between the mat and the weight, and the effect of this on the pressure and shear forces measured. Six replicates were conducted for each dressing. To measure microclimate, dressings were applied to a high humidity-containing chamber (∼90% RH), and the change in chamber humidity measured over 8 hours at a constant temperature. RESULTS: When weight was applied directly to the pressure mat, the average pressure recorded was 55 mmHg, and the average pressure gradient (shear) was 21 mmHg/cm. With Dressing A, the average pressure reduced by 52%, and pressure gradient (shear) by 46%. The other dressings reduced the pressure by 32% (B), 33% (C), and 22% (D), and average pressure gradient (shear) by 35% (B), 28% (C), and 31% (D). Microclimate test results showed Dressing A had reduced the humidity to 58% RH, Dressing B to 75% RH, and Dressings C and D to 83% RH. CONCLUSIONS: This study showed that all of the dressings reduced pressure and shear forces, but not all dressings are able to do this to the same extent. Dressing A maintained a much lower humidity in the microclimate test chamber, indicating that this dressing generated a more favorable microclimate by removing excessive moisture, while not completely drying out the environment.

1. International review. Pressure Ulcer Prevention: Pressure, Shear, Friction and Microclimate in Context. A consensus document. London: Wounds International; 2010.

Professional Practice—Restructuring in Health Care Settings, Strategies for Survival



Shannon Handfield, BSN, RN, CWOCN, , IMITS, Vancouver, BC, Bruce Gamage, RN, BSN, CIC, , Provincial Infection Control, Vancouver, BC, and Elizabeth Bryce, Dr, , Pathology and Laboratory Medicine, Vancouver, BC, Canada

ISSUE: Patients with complicated wounds require repeated dressing changes to promote healing. Dressings are expensive and often only a small portion is used during each dressing change. Nurses frequently save the unused portion of dressing for reuse on the same client; however, there are no specific protocols for safe storage. The BC Provincial Nursing Skin and Wound Committee, in collaboration with wound clinicians from the 6 health authorities, worked with the Provincial Infection Control Network (PICNet) to develop guidance for safely storing dressings. PROJECT: A literature review was performed to look for any existing guidelines on appropriately saving dressings, but none were found. A consensus process was used to develop guidance which has now been adopted in BC. RESULTS: Dressing supplies must be single client use only. Aseptic no-touch technique must be used for dressing changes. Saved dressings can be used only for no-touch or clean dressing changes. New dressings are required for sterile dressing changes. Sterile forceps and scissors are used to cut a piece of the dressing that fits into or covers the wound. The remaining dressing is placed into a new sterile C&S container or a new resealable bag labeled with the client's name, the date, and the name of the dressing. At the next dressing change, sterile forceps and scissors are again used to cut a piece of the dressing that fits into or covers the wound. The remaining dressing is then placed back into the container or bag. After 2 weeks, the container or bag and any remaining dressing pieces are discarded. LESSONS LEARNED: This Guideline standardizes a process that regularly occurs but has never been actually acknowledged. Standardizing will improve patient safety as well as redirect savings toward other patient care issues

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Stephanie Graham, RN, MSN, , Meidcal-Sugical Unit, Chicago, IL, Marianne Banas, RN, MSN, CCTN, , Nursing, chicago, IL, and Susan Solmos, RN, MSN, CWCN, , Center for Nursing Professional Practice and Research, Chicago, IL

PURPOSE: The purpose of this program was to increase organizational resources dedicated to the prevention of hospital-acquired pressure ulcers (HAPUs). OBJECTIVE: To extend the reach and scope of the Skin Care Team Champions and Certified Wound Care Nurses (CWCNs) by creating a senior skin care team with a systemwide focus on HAPU prevention. The wound care department at a Midwestern academic teaching hospital recognized the need to expand the knowledge and reach of its unit-based Skin Care Team champions. Nine nurses were recognized as having 10 years or more of dedicated service on the Skin Care Team and represent 3 different specialties (medical-surgical, hematology/oncology, and medical/surgical intensive care unit). A new role of senior Skin Care Team champions was created for these nurses, focusing on systemwide HAPU prevention. These senior Skin Care Team nurses are provided dedicated time to be involved in activities surrounding skin care. In addition to their usual Skin Care Team responsibilities, responsibilities of these senior nurses include, but not limited to: mentoring new Skin Care Team champions, developing evidence-based protocols for prevention of medical device-related pressure ulcers, and targeting resources toward units with HAPUs. Two of the 9 senior Skin Care Team champions were presented with the opportunity to attend a WOC nurse-accredited wound care program. A trustee endowment afforded the 2 senior Skin Care Team champions with the financial ability to participate in the wound care program to become CWCNs. OUTCOMES: Through this unique opportunity, long-standing Skin Care Team nurses have been provided additional opportunities to enhance their skill set and provide additional resources to the bedside to prevent HAPU. Part of a larger organizational initiative, the efforts of the Senior Skin Care Team champions have contributed to a 79% overall reduction in the hospital's HAPU rates over the past 2 fiscal years.



Stephanie Terry, BSN, RN, CWOCN, PCCN, HN-BC, , and Joseph Rudolph, BSN, RN, CWOCN, DWC, , Wound care, Philadelphia, PA

In 2013, a multidisciplinary “SWOT” team was formed to improve patient outcomes by leveraging appropriate nursing staff and disseminating pertinent data regarding available skin, ostomy, and wound care products. The institution has 2 wound, ostomy and continence (WOC) nurses, seeing about 75 total inpatients and outpatients weekly. Our hospital is a 74-bed facility, including 12 ICU beds and 8 stem cell rooms. The Director of Quality, Director of Nursing, and Senior Management supported the use of advanced skincare-educated nurses to provide education and standardization of products and protocols. Led by the WOC nurses, monthly prevalence studies and daily incidence assessments were implemented to better track pressure ulcer rates within the hospital using a risk monitoring system. SWOT is composed of 2 team-led RNs, and 35 members from departments, including inpatient and outpatient clinics, and the operating room. Each nurse underwent a 4-hour training course, spent a day with a WOC nurse, and conducts skin audits called “Wound Care Wednesdays.” SWOT reports high satisfaction with both their role as resources and assistance with competencies, and in their ability to improve a patient's quality of life. Quarterly prevalence rates in 2013 were as high as 11%. Since the inception of the SWOT, incidence rates of pressure ulcers have remained low: 1.025% in 2014, and 1% for 2015. As of November 2015, the prevalence rate is 0.4%. The implantation of daily incidence has improved transparency within our hospital and has been standardized throughout the entire organization. The last prevalence studies have shown zero hospital-acquired pressure ulcers and with pay for performance increasing the ability to show better outcomes is paramount. The utilization of skin teams may be something all oncology hospitals may want to implement.

Carson D, Emmons K, Falone W, Preston A. Development of pressure ulcer program across a university health system. J Nurs Care Qual. 2012;27(1):20–27.

Delmore B, Lebovits S, Baldock P, Suggs B, Ayello E. Pressure ulcer prevention program: a journey. J Wound Ostomy Continence Nurs. 2011;38(5):505–513. doi:10.1097/WON.0b013e31822ad2ab.

Ratliff C, Tomaselli N.). WOCN update on evidence-based guideline for pressure ulcers. J Wound Ostomy Continence Nurs. 2010;37(5):459–460. doi:10.1097/WON.0b013e3181f17cae.

Taggart E, McKenna L, Stoelting J, Kirkbride G, Mottar R.). More than skin deep: developing a hospital-wide wound ostomy continence unit champion program. J Wound Ostomy Continence Nurs. 2012;39(4):385–390.



Susan M. Scott, MSN, RN, WOCN, , Graduate Medical Education, Memphis, TN, Debra L. Fawcett, PhD, RN, , Kokomo, IN, Deena K. Young Guren, MSN, RN, CNOR, CNS-CP, , Surgical Services, Seattle, WA, and Cassendra A. Munro, MSN, RN, CNOR, , Santa Monica, CA

The incidence of perioperative pressure ulcers over the past 5 years has not decreased but increased (Chen, 2012). According to a 2014 publication from the National Pressure Ulcer Advisory Panel, the incident rate for pressure ulcers attributed to the operating room ranges from 5% to 53.4%. As a result, substantial patient harm has been reported leading to complications, disfigurement, disability, and death. Despite published guidelines specific to the operating room (OR), significant gaps in knowledge, practice, and research exist. The Association of Perioperative Registered nurses (AORN) chartered a task force including AORN subject-matter expert members and representation from the Wound, Ostomy and Continence Nurses Society. The task force has created a PPUP online toolkit for both association and society members. This online toolkit will contain: PPUP Program Quality Improvement (QI) roadmap, surgical specific evidence-based risk assessment tools and trigger systems, gap analysis and handoff communication tools, patient safety investigation and root cause analysis checklists, and current references. Additionally several webinars, downloadable slide decks, and posters will be available on various topics including surgical positioning, risk assessment, quality improvement, skin assessment, and documentation. The presentation will describe the toolkit components and illustrate a strategic plan to raise awareness, improve communication, and competency around a vision of eliminating patient harm from pressure ulcers in the high-risk surgical population. The toolkit is meant to strengthen perioperative pressure ulcer prevention efforts, supplementing or adding to an institution-wide comprehensive pressure ulcer prevention program.

Chen H, Chen X, Wu J. The incidence of pressure ulcers in surgical patients of the last 5 years. Wounds. 2012;24(9):234–241.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Haesler Emily (Ed.). Perth, Australia: Cambridge Media; 2014.

Lumbley J, Ali S, Tchokouani L. Retrospective review of predisposing factors for intraoperative pressure ulcer development. J Clin Anesth. 2014;26:368–374.

Black J, Fawcett D. Scott S Ten top tips: preventing pressure ulcers in the surgical patient. Wounds Int. 2014:5(4). Accessed February 10, 2015.

Scott S. Progress and challenges in perioperative pressure ulcer prevention. J Wound Ostomy Continence Nurs. 2015;42(5):480–485.



Tanya Martel, MS, RN, CWOCN, , Nursing, Winchester, MA

BACKGROUND: In 1992, the Agency for Healthcare Quality and Research (AHRQ) published clinical practice guidelines for the prevention of pressure ulcers (PU). Since then, research has continued to inform additional clinical practice guidelines through various organizations, including the WOC nurse and the NPUAP. While these guidelines are continually updated and provide the latest evidence on the prevention and treatment of PU, they provide far less guidance regarding the pragmatic application into everyday clinical practice. Research supports that the implementation of a comprehensive PU prevention program can reduce the incidence and cost associated with HAPU. Key components of successful programs include engagement of the nursing staff, good relationships among healthcare team members, and maintenance of the momentum over time. METHODS: We have a comprehensive and ongoing HAPU prevention program. Key components include monthly wound council meetings, mandatory annual wound and skin education, mandatory CWOCN nurse consults for HAPU stage II or greater, peer-to-peer education, review of all HAPU with unit staff, documentation review, use of evidence-based prevention protocols, full-day contact hour program, weekly skin rounds in ICU, performance improvement plans, and a visible, full-time CWOCN. RESULTS: Quarterly point prevalence is conducted on all clinical units for HAPU. Hospital prevalence rates were: 2013 (0.65%); 2014 (0.22%); and the first 3 quarters of 2015 (0.61%). Our data indicate a very low HAPU rate which we have successfully maintained for over 3 years. CONCLUSION: Our experience adds to the existing clinical evidence which supports that maintaining a culture of HAPU prevention in an acute care setting is an essential part of HAPU prevention. The cost of HAPU prevention can be offset by the cost avoidance realized from HAPU reduction. Hospitals would benefit by becoming more analytical in their approach to balancing the cost of comprehensive prevention program with savings from HAPU reduction.

Wound, Ostomy, and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Haesler Emily (Ed.). Osborne Park, Western Australia: Cambridge Media; 2014.

Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:08–0043.

Ostomy—Clinical Outcomes



Vashti Livingston, RN, MS, CWOCN, , Memorial Sloan Kettering Cancer Center, New York, NY

PURPOSE: An ambulatory WOC nurse examined the preoperative work flow of clients undergoing total pelvic exenteration. The standard of care at this institution is for clients to be seen preoperatively for stoma site marking. However, due to the complexity of this type of surgery, coordination of the WOC nurse visit along with gyn, colorectal, urology, and plastics was not always in the correct sequence for the WOC nurse to maximize the preoperative visit. The challenge was the administrative staff doing the scheduling did not understand the difference between this and a regular stoma site marking visit. The WOC nurse decided to educate them about this surgery and develop a work flow where the WOC nurse would be last after all the multiple consents were signed. OBJECTIVE: Previously a total pelvic exenteration case was sometimes scheduled with 2 WOC nurses as 2 separate 45-min stoma site marking visits. The WOC nurse met with an administrative supervisor and worked on this work flow to avoid a client potentially missing a WOC nurse visit as some patients left the clinic after the first marking. Education about the surgery was provided to the administrative staff and nurses. The visit time is 90 minutes, and only 1 ambulatory WOC nurse sees the client after all consents are signed to do the marking and education for 2 stomas, or a stoma and continent urinary diversion. When the term total pelvic exenteration is placed on the surgical list, the ambulatory WOC nurses are notified. This allows time for communication with the MDs about special circumstances (as these markings are not always standard). OUTCOME: The process has improved and the WOC nurses have been actively involved and aware of these cases much earlier than before this implementation.

WOCN Society and AUA Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Urostomy Surgery. J Wound Ostomy Continence Nurs. May-June 2015;42(3);253–256.

WOCN Society and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Colostomy or Ileostomy Surgery. J Wound Ostomy Continence Nurs. May-June 2015;42(3):249–252.

Wound—Product Selection and Innovations



Diana Villela-Castro, PhD, , Continuing Education, São Paulo, Brazil, and Vera Lúcia C. G. Santos, PhD, MSN, BSN, CWOCN, (TiSOBEST, -, Brazil), , Medical-Surgical Nursing Department, São Paulo, Brazil

The odor has highlighted as one of the main signs of infected fungating wounds. Described as intolerable and nauseating being caused by interaction of aerobic and anaerobic bacterias to colonize and infect the wounds. Aiming to reduce the microbial load location, has described the use of antiseptics and topical antibiotics, being more cited the metronidazole. In Brazil, metronidazole is available in the form of vaginal cream (8%-400 mg/5 g and 10%-500 mg/5 g), oral suspension (40 mg/ml), oral tablets (250 mg or 400 mg) and parenteral solution (0.5%). As there are no ready formulations of metronidazole 0.8% topical solution, handling becomes necessary (metronidazole tablets associated with saline, for example, off lable). As in Brazil, have topical solution polyhexanide (PHMB) 0.2% to treat infected wounds, was conducted a double-blind, randomized clinical trial to verify if PHMB is effective in odor management. Twenty-four patients were recruited, being 12 in controlled group (metronidazole 0.8%) and 12 in experimental group (PHMB 0.2%). Was used the TELER® scale (patient's odor impact, odor rating, discomfort in dressing changing), odor quality (extremely offensive, moderate offensive, small offensive, nonoffensive) and Ferrans and Powers Quality of Life Index (QLI). The odor was measured in day 0, day 4, and day 8, or until odor was rating as “non odor” by 3 people. There was significant difference between 2 groups (p < 0.001), showing that the PHMB is a therapeutic option to control the odor of fungating wounds. * The study was conducted in a cancer hospital, after approval by the “Ethics Committee of University of São Paulo” and “Antonio Prudente Foundation” (CAAE:04127512.9.0000.5392), and recorded in (NCT02394821), and funded by the “Foundation Research of the State of São Paulo” (2013/01179-4).

Castro DLV, Santos VLCG. Odor management in fungating wounds with metronidazole: a systematic review. JHPN. 2015;17(1):73–79.

Ramasubbu DA, Smith V, Hayden F, Cronin P. Systemic antibiotic for treating malignant wounds (protocol). Cochrane Database System Rev. 2015, Issue 4.

Adderley UJ, Holt IGS. Topical agents and dressing for fungating wounds. Cochrane Database Systematic Rev. 2014, Issue 5.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Vicky Bryan, RN, BSN, CWON, , Wound, Ostomy Nursing Acute Care, Austell, GA

PURPOSE: The purpose of the study was to examine the effectiveness of a multi disciplinary clinical pathway on implementation of negative pressure wound therapy (NPWT) in the operating room (OR) environment. SUBJECTS AND SETTING: The study sample comprised of 143 consecutive surgical cases where negative pressure wound therapy was initiated in the perioperative setting. The research environment is in a 350-bed acute care hospital in the Southeastern United States. METHODS: Data collection and analysis were guided by a quasi-experimental pass/fail design. A collaborative approach between the OR, wound ostomy continence nurse (WOC nurse), surgeon, and the case coordinators was created. All departments worked together to contribute to the pathway. The OR staff was educated on the NPWT process and the surgeons were instructed on the initiation of the NPWT orders prior to the patient advancing to the postoperative setting. The WOC nurse created a formal notebook with written instructions and machine sign out sheets. A data sheet, discharge planning tool was created and utilized to calculate and reflect the process compliance. A monthly data report is provided to the OR clinical supervisor. The results are discussed in the staff meetings. The frequent communication of the data reminds the staff of the process. RESULTS: Initiation of the NPWT clinical pathway was associated with increased NPWT physician order initiation, alternative dressing instructions, WOC nurse consultations, and collaboration between the surgery department, WOC nurse, surgeons, and case coordination services. The clinical pathway reached a total compliance rate of 86% from February to August. CONCLUSION: Communication tools are essential for health care systems to provide quality care and positive outcomes. The new NPWT Clinical Pathway is a successful communication tool that provides the staff with a process to prevent variation in patient care with in the surgical environment.

Chu G. A defined peritonitis clinical pathway in the emergency department improves outcomes for peritoneal dialysis patients. Renal Soc Australasia J. 2014;10(1):30–33 4p.

Clinical Pathways: A Catalyst for the Adoption of Hypofractionation for Early-Stage Breast Cancer. (2015). International Journal of Radiation Oncology, Biology, Physics, 93(4), 854–861 8p. doi:10.1016/j.ijrobp.2015.08.013

Wang H, Zhou T, Tian L, Qian Y, Li J. Creating hospital-specific customized clinical pathways by applying semantic reasoning to clinical data. J Biomed Inform. 2014;52:354–363 10p. doi:10.1016/j.jbi.2014.07.017

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Vita Boyar, MD, , Pediatrics, New Hyde Park, NY

Neonatal and pediatric patients undergoing extracorporeal membrane oxygenation (ECMO) for provision of cardiopulmonary support possess many risk factors for pressure ulcer development. An initiative to reduce pressure ulcers in this high-risk population was conducted. After the review of current statistics/guidelines, the PU Prevention Bundle was developed, incorporating 6 elements that National PU Advisory Panel (NPUAP) endorses. Compliance with bundle elements was unsatisfactory. Incidence of PUs was significant. Culture of eliminating “unacceptable” hospital acquired conditions (HAC) was not widespread and embraced; complacency instead of proactivity prevailed. Suboptimal knowledge of preventative measures, risk factors and poor compliance with assessment and documentation were noted. Treatment was inconsistent. ICU patients represented majority, specifically cardiac and ECMO recipients. An educational program was put together, including bundle modification into a simple 1-page tool “S.K.I.N.D.E.E.P.”, demonstrating a pictorial of at-risk areas and preventative products. It was printed in ECMO manual and placed by bedside of every ECMO recipient. SKINDEEP was piloted ECMO recipients. Review of preimplementation era (03/12-06/13) revealed 15 PUs. Fourteen patients underwent 149 ECMO days (6 patients were PU-free, 8 had 1 or more PU). SKINDEEP was implemented in 06/2013. ECMO staff was educated on PU prevention, shifting the thinking that PU in ICU is unavoidable. Emphasis was placed on mandatory prevention, parent involvement in skin care, decreasing morbidity and cost of care and avoiding reportable “never events.” Postimplementation era (07/13-10/15) included 24 ECMO recipients, 183 ECMO days and only 1 PU. We know that average cost of Stage 3 or 4 PU is ∼$40.000-70.000/stay. Therefore, decrease in incidence by ∼99% translated into potential savings of $500.000/year for our hospital. Cultural shift is slow, but decrease in numbers inspires bedside caregivers to embrace change for the sake of patients' safety. We know that most PUs are avoidable and the key is education, culture change, constant audits, and feedback element.

1. Curley M, Quigley S, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284–290.

2. McCord S, McElvain V, et al. Risk factors associated with pressure ulcers in the pediatric intensive care unit. J Wound Ostomy Continence Nurs. July 2004;31(4):179–183.

3. Edsberg LE, Langemo D, Baharestani MM. Unavoidable pressure injury: state of science and consensus outcomes. J Wound Ostomy Continence Nurs. July 2014;41(4):313–334.

Wound—Product Selection and Innovations



Yu Chen, Wound Expert ICW, , Dressing Room, Chengdu

ABSTRACT: Negative pressure wound therapy (NPWT) technology has achieved a significant clinical effect. At present, there are 3 major disadvantages of NPWT at home and abroad.

One of these disadvantages is high price that the majority of the patients cannot afford; the other is large volume that is not easy to carry; another disadvantage is lack of reliability and stability in some simple negative-pressure devices despite their low prices. In order to overcome the above disadvantages and meet the clinical needs of patients, this paper has referred to the Guidelines for Negative Pressure Wound Therapy in Europe, used the hospital's existing materials and self-designed a pocket-type negative-pressure wound closure device. This device is characterized by small volume (may be put into pockets), adjustable negative pressure, low price, reliable performance. This device can reduce the cost of high technology and belongs to a leading technology in China. This device can shorten the healing time of chronic wounds in clinical practice and reduce the total cost of the therapy, which conforms to the current situation of Chinese people's livelihood and is widely recognized by the majority of patients. This device has obtained three China National Utility Model Patents in 2014, with patent No. 201420305835.3, 291420305940.7, and 201420305942.6, respectively.

Continence - Evidence-Based Treatment and Management



Dongmei Li, , Danli Fu, , Lanlan Chen, , Yuting Han, and Gengsheng Mao, , Beijing

OBJECTIVE: To investigate the nursing efficacy of women's urine drainage device in patients with urinary incontinence following stroke METHODS: We retrospectively analyzed 107 female patients with stroke admitted to Neurovascular Surgery Department of General Hospital of Armed Police Forces between Jan 2014 and July 2015. The patients were divided into treatment group (53 cases) and control group (54 cases), in whom urinary incontinence was managed with women's urine drainage device and traditional care devices respectively. We discussed about the advantages and disadvantages of different urine collection devices by comparing urinary tract infections, pressure sores, genital skin swelling and ulceration and life quality of patients. RESULTS: There was statistically significant difference between the two groups in terms of urine leukocyte count (33.3% for the treatment group and 71.4% for the control group, respectively, P < 0.05) and urine culture positive rate (10.4% for the treatment group and 18.4% for the control group, respectively, P < 0.05). Besides, the incidence rate of the adverse events of urine leakage, pressure sores, genital swelling and ulceration was significantly lower in the treatment group, while scoring for the Incontinence Quality of Life questionnaire (I-QOL) is statistically higher in the treatment group. CONCLUSION: The new-type women's urine drainage device help reduce the incidence of urinary tract infections, pressure ulcers, penile swelling, ulceration, and some other complications, as well as improve patients' life quality. It is worth clinical popularization.

KEY WORDS: stroke, urinary incontinence, urine collection devices, nursing care


RESEARCH ABSTRACTSProfessional Practice—Clinical Practice Outcomes;Standards of Care; Clinical Pathways



Ann Marie Kassab, MSN, RN, CWCN, , Tessa Terwilliger, BSN RN, , Gloria Skinner, MSN RN, , Sammuel I. Hammerman, MD, MMM, FCCP, , Lisa K. Snyder, MD MPH, , and Tony Grigonis, PhD, , Mechanicsburg, PA

A mentoring program (MP) for administrative and clinical staff was developed to reduce the incidence of hospital-acquired pressure ulcers (HAPUs) in long-term acute care hospitals (LTACHs). LTACHs treat chronic critically ill (CCI) patients with long hospital stays in which malnutrition, limited mobility, hemodynamic instability, and acute illness can contribute to HAPU development. Following an initial administrative conference call, clinical leadership conducted calls to review causes of high pressure ulcers rates, including program adherence, formulary-based prevention strategies, workflow, wound etiology, and understanding/adherence to reporting guidelines. Action plans were developed to address the deficits. HAPU rates were the number of HAPUs divided by patient days times 1000. HAPU rates were compared 6-month pre- and 6-months post-MP implementation in 9 MP and 9 randomly selected control group LTACHs. A General Linear Model with repeated measures was used to determine the significance of the mean HAPU rate changes. For the 9 MP LTACHs, the average HAPU rate decreased from a preimplementation rate of 6.09 HAPUs (95% CI: 4.98, 7.20), to a postimplementation rate of 2.78 HAPUs (95% CI: 1.08, 4.49) (GLM repeated measures design; F(1, 8) = 17.025, p = .003; partial eta squared = 0.680). A control group of a random sample of 9 LTACHs that did not participate in the MP program had no significant change in HAPU rates pre- to post-MP implementation. Overall average HAPU rate from the MP LTACHs began declining prior to implementation of the MP but decreased at a more rapid rate following MP implementation. A mentoring program drilled down into causative factors associated with elevated HAPU rates was shown to be successful in significantly reducing HAPU rates in LTACHs that had a history of elevated HAPU rates. Similar programs may be effective in reducing HAPUs in high acuity and other critical care settings.

Continence—Evidence-Based Treatment and Management



Anne Jinbo, PhD, APRN-RN, MPH, CWOCN, CPNP, , Honolulu, HI and Donna Z. Bliss, PhD, RN, FAAN, FGSA, , School of Nursing, Minneapolis, MN

BACKGROUND: Adolescents with neurogenic bowel conditions need to assume performance of their prescribed bowel management program (BMP) but information about their adherence is lacking. PURPOSE: To describe adolescents' level of adherence to prescribed BMPs and examine factors influencing their adherence. METHODS: Adolescents in the practice of a CWOCN pediatric nurse practitioner were invited to participate in this study with a descriptive design. Level of adherence to BMPs and adherence facilitators and barriers were assessed using lists of specific factors and open-ended questions, whose development was guided by the Reason Action Approach framework. Frequencies of responses to lists were calculated; responses to open-ended questions were analyzed for themes using content analysis. RESULTS: Thirty adolescents (age = 16 (4) Mean (SD) years; male = 57%; Asian/Pacific Islander = 66%, white = 10%, other = 23%) participated; 90% were enrolled in school and 23% of those had special-education classes. 52% of adolescents adhered to their BMP 75%-100% of the time; 40% had <50% adherence to BMP. Specific perceived benefits of BMPs were: avoidance of accidents (80% of adolescents), increased confidence around friends (80%), and feelings of normalcy (80%). Specific barriers to BMPs were: continued accidents (36% adolescents), feeling different than others (33%), and length of time to complete BMPs (30%). Themes of factors facilitating BMP adherence were interventions to help ease defecation, benefits of having a BMP, and being able to control timing of BMP routine. Themes of barriers to BMP adherence were physical discomforts/side effects, lengthiness of BMP, and need for physical assistance. CONCLUSIONS: Approximately half of adolescents need consultation from WOC nurses to improve adherence to prescribed BMPs, and study findings offer guidance for developing appropriate strategies. Decreasing barriers to adherence may include reducing physical side effects, adjusting BMPs according to developmental/physical abilities, and providing emotional support. Reinforcing BMP benefits and allowing choice in timing of BMP routine may promote continued adherence.

Christensen AJ. Patient Adherence to Medical Treatment Regimens Bridging the Gap Between Behavioral Science and Biomedicine. New Haven: Yale University Press; 2004.

Fishbein M, Ajzen I. Predicting and Changing Behavior: The Reasoned Action Approach. New York: Psychology Press Taylor and Francis Group; 2010.

Ludman L, Spitz L. Coping strategies of children with fecal incontinence. J Pediatr Surgery. 1996;31(4):563–567.

Michaud PA, Suris JC, Viner R. The adolescent with a chronic condition. (Discussion Paper). Geneva, Switzerland: World Health Organization; 2007.

Taddeo D, Egedy M, Grappier J-Y. Adherence to treatment in adolescents. Paediatr Child Health. 2008:19–24.

Wound—Nutritional Issues in Wound Healing



Annette Gwilliam, RN, BSN, CWS, ACHRN, , Utah Valley Wound Care and Hyperbaric Medicine, Provo, UT, and Danielle Banks, MSN, Ed, BSN, RN, , College of Health Professions, Salt Lake City, UT

Wounds that heal poorly cause a significant burden on the wound care patient and on the United States healthcare system.1 Wound healing is a complex process with many complicating factors. One significant factor is nutrition.2 Malnourished wound care patients have a higher risk of being hospitalized and they also have a high mortality rate.3 There are several nutritional screening tools; however, Biscardi4 found that there is not a single nutritional screen that will provide a full nutritional status and none are specifically geared to wound healing. In working to develop a tool, we wondered if there would be a difference between the factors that dieticians and wound care nurses (WCN) think are important for wound healing. Our IRB-approved project was a qualitative survey of 54 dieticians and WCNs. We gathered demographic information including age, education level, years of experience, and national certification. We listed 16 nutritional factors to rank “in order of importance when considering a patient's nutrition and wound healing.” The choices included items related to: weight, swallowing, oral deformities, medications/supplements, comorbidities, nutrients, blood sugar levels, assistance needed for ADLs, and alcohol. After the survey items were statistical analyzed, we found that most rankings were similarly. Highly important to both groups were diabetes and >2 servings/day of protein. Moderately important to both were: ADLs, chewing problems, fruits/vegetable and >10 medications. Less important were amount of dairy, herbs/supplements, and alcohol consumption. Our biggest surprise was that 80% of dietitians ranked “gained/lost 10 or more pounds without trying” as first or second while only 25% of WCNs ranked it at that level. The highest ranking for WCNs was presence of comorbidities. In retrospect, we would change some of the risk factors to include appetite changes and BMI. We would also widen settings, in our study 90% worked in acute care.

Liang L, Thomas J, Miller M, Puckridge P. Nutritional issues in older adults with wounds in a clinical setting. J Multidiscip Healthc. 2008;1:63–71.

Guo S, DiPietro L. Factors affecting wound healing. Crit Rev Oral Biol Med. 2010;89(3):219–229.

Neelematt F, Thijs A, Seidell J, Bosmans J, Bokhorst-de van der Schueren M. Study protocol: cost-effectiveness of transmural nutritional support in malnourished elderly patients in comparison with usual care. Nutr J. 2010;9(6).

Biscardi M. Nutritional screening and assessment tools. Published 2011.

Wound—Evidence-Based Interventions



Marc Robins, DO, MPH, , Intermountain Healthcare-Utah Valley Wound Care and Hyperbaric Medicine, Provo, UT, and Annette Gwilliam, RN, BSN, CWS, ACHRN, , Utah Valley Wound Care and Hyperbaric Medicine, Provo, UT

Clinical trials are a way to study new products for safety/effectiveness (1). Ongoing research on new devices is essential to advance wound care. We evaluated an innovative new device on aspects important to patients and providers in wound healing. Our study consisted of 3 components: clinical trial, retrospective chart review, and surveys. After receiving IRB approval, 15 enrolled patients received 57 separate procedures. This nonrandomized, unblinded trial involved placement of a novel fluid delivery system instilling either small amounts of 3% gentamicin solution, sterile water, or normal saline at a constant rate to partially saturate a semiocclusive pad. The dressing was applied to the wound and the activated device left in place for up to 5 days. A survey was completed at each visit by the provider analyzing application, removal, and device functioning. Patient questions included the ability to perform ADLs. A retrospective chart review showed data on wound progression before/after the device administration. SAFETY: No adverse events were reported during the study and no incidents between clinic visits; varying degrees of maceration of the periwound affected wound healing in 11% of the cases. EASE OF USE: Application time decreased to as little as 10 minutes; the device was deemed “intuitive.” Removal of the device received 89% of clinicians rating as “easy.” IMPACT ON ADLs: 91% of patients responded that the device posed no limitations on their ADLs; 4% even stated that it enhanced their daily activities. HEALING RATES: determined to be favorable with 85% of the device applications resulting in wound healing rated “as anticipated” or “better than anticipated”; 14 out of 15 patients (93%) had a reduction in wound surface area. CONCLUSION: Ease of use with favorable patient acceptance and possible improved healing rates suggests this device may have an application in wound care.

1. Beard S. What does it mean to participate in a wound care clinical trial? Wound Care Advisor. 2015;4(1):18–21.

Wound—Preventative Practices New



Barbara Pieper, PhD, RN, ACNS-BC, CWOCN, FAAN, , Detroit, MI, and Thomas N. Templin, PhD, , Wayne State University, Detroit, MI

PURPOSE: Falls are a concern in health care. The purpose of this project was to examine fall occurrence, fall injuries, balance confidence, and lower body strength in persons seeking outpatient wound care. DESIGN/METHODOLOGY: This was a quality improvement project; it used a cross-sectional, comparative design. Participants responded to demographic questions, the Activities-specific Balance Confidence Scale (ABC), fear of falling, fall numbers, and injuries, and performed the 30-second chair rise test for lower body strength. Fall data were collected for each person for a mean of 4.09 months (SD = 1.61; range 1-7 months). RESULTS: Patients seeking wound care (N = 106; mean age = 59.94 years) included men (n = 70) and women (n = 36); 101 were African American. Sixty patients reported falling; 47 were recurrent fallers. Twenty patients stated they were injured, but did not seek emergency care. Higher number of total falls was significantly related to more comorbidities. Total falls were significantly related to fear of falling and ABC Scale scores. Of these patients, 97 were divided into those with injection-related venous ulcers (IRVU = 65) and those with venous ulcers from other causes (VUs-other = 32). Those with IRVU and VUs-other did not differ significantly by age, sex, race, pain rating, number of falls, and fear of falling. Those with IRVUs (7.30) performed significantly more chair rises than those with VUs-other (4.72). Persons with IRVUs had significantly higher ABC Scale scores (63.24%) than those with VUs-other (49.38%). Persons with VUs-other were heavier and had more comorbidities, but these variables did not explain differences in chair rise or ABC scores. CONCLUSIONS: Falls were a common occurrence. Thus, long-term risk for fall injury would be high. Further research is needed to clarify the interactions between VU risk and patient factors such as strength, age, agility, and impaired cognition.

Wound—Psychosocial and Quality of Life Aspects



Barbara Pieper, PhD, RN, ACNS-BC, CWOCN, FAAN, , Detroit, MI, and Thomas N. Templin, PhD, , Wayne State University, Detroit, MI

PURPOSE: Sleep is a physiologic and behavioral process essential for proper functioning of the body and believed important for wound healing. This study compared sleep quality of persons with (VU+) and without (VU−) injection-related venous ulcers and correlations of global sleep quality with health, physical activity, and demographic and venous ulcer variables. METHODS: A cross-sectional design was used. Instruments included the Pittsburg Sleep Quality Index (PSQI), Mini Nutrition Assessment (MNA), PROMIS questions about general physical health, fatigue, emotional problems and quality of life, Brief Pain Inventory worst pain rating, Positive Attitude and Motivation for Physical Activity Scale, wound assessment, and demographic factors. RESULTS: The participants were 31 VU+ and 30 VU− (men [n = 35] and women; mean age = 54 years). The 2 groups did not differ on the PSQI scales in terms of time going to bed, minutes to fall asleep, time awakening, hours slept, and time in bed. Those VU+ compared to VU− took more medication to help sleep (p < .03). There were no significant differences in PSQI correlations across groups. A higher number of comorbidities, worse pain, poorer nutrition, poor physical health rating, greater fatigue, more emotional problems, and poor attitude toward physical activity were related to greater sleep disturbances for all participants. Both groups had mean Global PSQI scores greater than 5 (VU+= 7.83 and VU−= 8.2), indicating sleep problems. CONCLUSIONS: These findings add to the literature about sleep quality by comparing persons VU+ and VU−. It is important to consider sleep for patients with wounds because they can have many factors that negatively affect sleep.

Wound—Preventative Practices New



Barbara Pieper, PhD, RN, ACNS-BC, CWOCN, FAAN, , Detroit, MI; Mary Kathryn Keves-Foster, MSN, RN, , JoAnn Ashare, MSN, RN, ACNS-BC, , Mary Zugcic, MS, RN, ACNS-BC, , Maha Albdour, RN, APHN-BC, , and Dalia Alhasanat, BSN, RN, , College of Nursing, Detroit, MI

PURPOSE: Learning about wounds and their care in undergraduate nursing education is critical because nurses participate in decisions related to wound care. The purposes of this quality improvement project performed in an introductory baccalaureate nursing course were to identify: (a) the types of wounds that patients assigned to beginning students had; (b) the wound care procedures and dressings students were exposed; and (c) students' level of participation in wound care. METHODS: This project used a descriptive design. The data were collected from faculty's (n = 5) anecdotal records about the students' (n = 49) clinical experience for 9 clinical days in acute care hospitals (n = 3). RESULTS: Across the patient care experiences, 75 patients had a wound. The most common wound was a surgical incision (n = 49; 65%) located on the abdomen (n = 37; 75.5%) and was closed (n = 36; 73.5%). Twenty-six patients had a pressure ulcer with the most common being Stage II. The most common dressing was dry gauze (n = 29). Wet-to-dry gauze was used on 18 wounds. Wound irrigation was recorded for 24 wound protocols and done with a bulb syringe or pouring solution from a container. Wound care was generally performed as nonsterile. For 25 experiences, students did wound care independently or with the supervision of the instructor; 16 students watched the care performed by another clinician; 10 students participated with another nurse in the wound care. For 22 patients, the wound care was neither observed nor done because of unit/care restrictions. CONCLUSIONS: Beginning nursing students had some, but limited, clinical experiences with patients who had wounds, but more and varied wound care experiences are highly desirable. Nursing students need continued experience understanding varied dressings and wound treatments as well as principles of wound management. Wound care education needs to be examined across the entire curriculum and in varied clinical settings.

Continence—Issues in Bladder and Bowel Continence Management



Carolyn Hassan, MSN, RN, CWCN, , Wound Healing, Richmond, VA

Urinary incontinence (UI) and fecal incontinence (FI) were reported in the literature as prevalent yet underreported conditions in community-dwelling adults. UI and FI have been documented to lead to a frequently painful and persistent skin condition labeled incontinence-associated dermatitis (IAD). Despite literature that reflected decreased health-related quality-of-life scores associated with UI and FI, many adults did not seek medical help for these conditions. This research study investigated the barriers to seeking help for UI, FI, and IAD in community-dwelling adults. Two church congregations participated in completion of a survey to gather data on the prevalence of UI, FI, IAD, and barriers to seeking help. A total of 145 persons between the ages of 21 to over 80 years of age participated. Prevalence rates were determined as were 3 barriers to seeking help: the belief that UI and FI were a normal part of aging, the ability of those affected to self-manage with absorbent pads and briefs, and the belief that the condition was not severe enough to seek medical help. Further analysis of these barriers by gender and type of incontinence demonstrated differences between males and females and by type of incontinence. Less than a quarter of those affected by incontinence indicated that they had sought medical help for UI and FI; however, over a third of those affected indicated the desire for written literature on these conditions as a follow-up to this research study. The information gained regarding barriers to seeking help in this community-dwelling adult population was used to develop and provide education on incontinence treatments and incontinence skin care for these communities. Church congregations, community centers, and other locations where individuals gather may serve as access points for wound, ostomy, and continence nurses to assess for the need for incontinence education.

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Westra BL, Bliss DZ, Savak K, Hou Y, Borchett A. Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care. J Wound Ostomy Continence Nurs. 2013;40:25–33.

Willson MM, Angyus M, Beals D, et al. Executive summary: a quick reference guide for managing fecal incontinence (FI). J Wound Ostomy Continence Nurs. 2014;41:61–69.

Yuan HB, Williams BA, Liu M. Attitudes toward urinary incontinence among community nurses and community-dwelling older people. J Wound Ostomy Continence Nurs. 2011;38:184–189.

Wound—Evidence-Based Interventions



Catherine R. Ratliff, PhD, APRN-BC, CWOCN, , University of Virginia Health System, Charlottesville, VA

INTRODUCTION: A new surfactant-based burn and wound dressing that donates moisture and promotes a clean wound environment was evaluated on 20 patients with lower extremity wounds. MATERIALS AND METHODS: This descriptive IRB approved study addressed the use of the PUSH (Pressure Ulcer Scale for Healing) Tool to measure healing with the use of a surfactant-based gel. The PUSH tool requires wound assessment with the assignment of an appropriate score for the 3 parameters of size, exudate amount, and tissue type. When these parameters are scored, the final PUSH score ranges from 0 (healed) to 17 (most severe wound). All patients seen at the wound clinic were given a PUSH score prior to application of the gel and at subsequent clinic visits. The wounds selected were full thickness and had been present for greater than 4 weeks. RESULTS: Twenty patients participated in this case series involving 11 women and 9 men with a mean age of 65. All 20 of the patients had peripheral vascular disease. The mean PUSH score before the surfactant-based gel was applied was 10.2 and posttreatment was 7.5. All patients had a decrease in their pretreatment to the first clinic visit posttreatment PUSH Tool score. In this study, all wounds entered into a healing trajectory using this surfactant-based gel as evidenced by the decrease in PUSH Tool scores. CONCLUSION: All 20 patients had a decrease in PUSH Tool scores from pretreatment to posttreatment, indicating that the surfactant-based gel may be an effective dressing in the management of lower extremity wounds.

Hon J, Lagden K, McLaren AM, et al. A prospective, multicenter study to validate use of the PUSH in patients with diabetic, venous, and pressure ulcers. Ostomy Wound Manage. 2010;56(2):26–36.

Ratliff CR, Rodeheaver GT. Use of the PUSH tool to measure venous ulcer healing. Ostomy Wound Manage. 2005;51(5):58–63.

Wound—Preventative Practices New



Catherine VanGilder, MBA, BS, MT, CCRA, , and Corrine Algrim-Boyle, RN, MS, , Clinical Research, Chicago, IL; Charlie Lachenbruch, PhD, , R&D, Batesville, IN; Stephanie Meyer, BS, , Clinical Information Services, Batesville, IN

PURPOSE: Pressure ulcer (PU) prevalence allows benchmarking within and across facilities. The International Pressure Ulcer Prevalence™ Survey is unique as it includes a variety of care settings and participants include community and larger teaching facilities. The purpose of this study is to present 10 years of US prevalence data (2006-2015) by care setting. METHODS: Facilities volunteer to participate in the IPUP survey. Internal clinical teams collect data during a predetermined 24-hour period which includes demographics, pressure ulcer prevalence, and other pertinent data. Aggregate data are released to the sponsor and was analyzed for this study. RESULTS: A total of 918,621 US patients were surveyed 2006-2015. Overall Prevalence (OP) (all facilities) declined from 13.5% (2006) to 9.3% (2015). Facility Acquired Prevalence (FAP) declined from 6.2% (2006) to a range of 3.1%-3.4% (2013-2015). Acute Care (AC) OP was 13.3% in 2006 and declined to a range of 8.8%-9.3% (2012-2015). AC-FAP declined from 6.4% (2006) to 2.9% in 2015, with 2008-2009 showing the most aggressive decline. Long-Term Acute Care (LTAC) had the highest OP at 32.9% (2006), and declined to 28.8% (2015), FAP was 9.0% declining to 5.6% respectively. Recently Long Term Care (LTC) FAP has risen from 3.8% (2013) to 5.4% (2015). Rehab FAP was between 2.6% and 2.8% over the last 3 years. DISCUSSION: In 2007, CMS announced that they would no longer pay for the cost of care of FA-PUs in AC. AC FAP declined a full 1% during 2008-2009, likely indicating the focus on PU prevention. Continued AC prevention efforts have achieved an overall 3.5% reduction in FAP (2006-2015). This decline is similar in Rehab; however, LTAC and LTC are more variable, however sample sizes are lower. CONCLUSIONS: AC and Rehab OP and FAP have declined significantly over this 10-year period, while we see variation in LTC and LTACs.

Ostomy—Psychosocial and Quality of Life Aspects



Cherisse Tebben, MSN, MPH, CWOCN, FNP-BC, , Craig Hospital, Englewood, CO; Xiomara Acosta, RN, BSN, and Mary Vidmar, RN, MS, CRRN, , Outpatient Clinic, Englewood, CO

PURPOSE OF THE STUDY: 1. To determine the quality of life from the patients' perspective in those who have elected the Mitrofanoff procedure. 2. To describe which demographic factors and SCI-related factors positively influence quality of life in those who have elected the Mitrofanoff procedure. METHODOLOGY: The sample population was identified retrospectively from chart reviews. Thirty-four participants, 16 years of age and over, having the Mitrofanoff procedure were interviewed by phone or in person using: 1. A demographic questionnaire and a SCI-related questionnaire developed specifically for this study. 2. The English version of the Qualiveen (Quality of Life) Questionnaire specific to feelings and fears related to bladder issues. STATISTICS: Participant demographic information was tabulated and reported as frequencies or means. A qualitative research approach was used to generate exploratory information. RESULTS: The quality of life was reported as significantly better in patients undergoing the Mitrofanoff procedure with majority of participants reporting that, given the option, they would again elect having the Mitrofanoff procedure performed. There are specific demographic factors (sex, race, marital status, living situation) and SCI-specific factors (level of injury, pre-Mitrofanoff bladder management, bladder issues leading to electing the Mitrofanoff) influencing the feeling of positive quality of life in the outpatient setting. CONCLUSIONS: The initial results demonstrate that the Mitrofanoff procedure positively correlates with better quality of life for SCI outpatients, especially with specifically identified demographic and SCI related factors.

Wound—Product Selection and Innovations



Helen Thomason, PhD, , Holly Wilkinson, BSc, , and Matthew Hardman, PhD, , Faculty of Life Sciences, Manchester; Christian Stephenson, BSc, , and Jodie Lovett, MEng, , Research and Development, Knutsford; Andrew McBain, PhD, , School of Pharmacy and Pharmaceutical Sciences, Manchester

INTRODUCTION: Debridement remains the foundation to wound bed preparation, removing nonviable tissue and biofilm infections. Recently, monofilament debriding devices have emerged as an easy and convenient alternative to traditional surgical debridement. The advantages are ease of application, reduced pain and reduced need for clinically trained personnel. However, data on the efficacy of monofilament debridement to remove biofilm infection is limited. METHODS: Here we assess the effectiveness of a monofilament debriding mitt consisting of polyester fibers, to remove biofilms. Pseudomonas aeruginosa (NCTC 10780) biofilms were grown for 24 or 48 hours in vitro before applying to porcine skin for an additional 24 hours. Biofilm removal was assessed by attaching the monofilament debriding mitt to a computer-controlled, mechanical brushing device. Biofilm were brushed in a linear fashion for 50 cycles at a constant rate and pressure. Remaining biofilm was visualized and quantified with the cell viability dye, presto blue, and scanning electron microscopy (SEM). In addition, 72-hour P. aeruginosa biofilms were applied to excisional mouse wounds and allowed to attach and grow for a further 72 hours, after which wounds were debrided with the monofilament debriding mitt. Remaining bacteria were quantified by standard plate counts. RESULTS: Quantification of viable 24- and 48-hour biofilms remaining on the porcine skin revealed significantly less biofilm when debridement was performed with the monofilament debriding mitt compared to NA Gauze control (P < 0.05, Mann-Whitney U test). Visualization of remaining biofilm by SEM confirmed reduced bacteria when debridement was performed with the monofilament debriding mitt. In addition, monofilament debridement significantly reduced biofilm levels in the mouse wound model (P < 0.05, Mann-Whitney U test). CONCLUSIONS: Monofilament debriding mitt effectively removes P. aeruginosa biofilms from wounds and therefore acts as a less-invasive method of wound debridement than traditional sharps debridement.



Helen Thomason, PhD, , and Matthew Hardman, PhD, , Faculty of Life Sciences, Manchester; Christian Stephenson, BSc, , and Jodie Lovett, MEng, , Research and Development, Knutsford; Andrew McBain, PhD, , School of Pharmacy and Pharmaceutical Sciences, Manchester, UK

INTRODUCTION: Dressings containing metallic silver (Ag0) and/or singly ionic silver (Ag1+) are widely used for their antimicrobial effects. New technology can now incorporate silver oxysalts into dressings at higher oxidative states (Ag2+ and Ag3+). This high oxidative state silver powerfully interacts with microbes and thus displays potent antimicrobial activity against planktonic bacteria and biofilms. However, data is limited on the effects of silver oxysalts on healing once infection is cleared. METHOD: Here we assess the effects of silver oxysalts on healing in vitro and in a murine excisional wound model independent of infection. Human keratinocyte and fibroblast scratch wound assays were performed with and without silver oxysalts and wound closure assessed after 24 hours. In addition, dressings containing silver oxysalts were applied to 6-mm murine excisional wounds (n = 10) and wounds were harvested after 3 and 7 days. The effects of silver oxysalts on wound area, reepithelialization, and inflammation (immunohistochemistry for macrophage and neutrophils) were assessed. RESULTS: Significantly we show that silver oxysalts promote closure of human keratinocyte scratch wounds (P < 0.05, Mann-Whitney U test) and have no adverse effect on human fibroblast scratch wounds independent of their antimicrobial effects. Furthermore, silver oxysalts significantly reduced wound area and promoted reepithelialization of murine wounds (P ≤ 0.05, Mann-Whitney U test). Concomitantly, a reduction in the number of macrophage and neutrophils within the wound was observed with silver oxysalt treatment (P < 0.05, Mann-Whitney U test) compared to control dressings. CONCLUSIONS: Collectively, these data indicate that silver oxysalt-containing dressings have no adverse effect on healing when infection not present or cleared. Strikingly we find that silver oxysalts actually promotes wound repair, increasing the rate of reepithelialization and dampening inflammation.

Wound—Evidence-Based Interventions



Adrienne Gilligan, PhD, , Life Sciences, Fort Worth, TX, Marissa Carter, PhD, MA, , Strategic Solutions, Inc., Cody, WY, Curtis Waycaster, PhD, , Market Access, Fort Worth, TX and Caroline Fife, MD, CWS, , The Woodlands, TX

OBJECTIVE: Assess the clinical effect of cadexomer iodine (CI) relative to medicinal honey in the hospital outpatient department (HOPD) setting for the treatment of venous leg ulcers (VLUs). METHODS: Retrospective de-identified electronic medical records from 2007 to 2013 were extracted from the U.S. Wound Registry (USWR). The USWR is a registry of chronic wounds from more than 100 HOPD wound centers in the United States and Puerto Rico. A propensity score model using a 1-to-1 matching approach was performed to test for treatment effect and adjust for covariance between wounds that treated CI versus medicinal honey. RESULTS: A total of 9313 patients, 22,312 wounds, and 186,023 visits for VLU were identified. The majority of patients were female (51.9%) with an average age of 61.6 (SD = 17.7). Approximately 21.3% had a history of hypertension, 8.3% had a history of venous insufficiency with diabetes, and 2.5% received immunosuppressive agents. Mean baseline wound surface area was 7.9 cm2 (SD = 14.4). The average wound age at baseline was 8.5 months (SD = 27.8) and average treatment duration was 2.9 months (SD = 4.9). Of the 22,312 VLUs, approximately 3.3% received CI (n = 738) and 2.0% received medicinal honey (n = 441). VLUs treated with medicinal honey were significantly more likely to be active and chronic after 60 days (p < 0.0001) relative to wounds treated with CI (12% vs 8%, respectively). Furthermore, VLUs treated with CI were significantly more likely (p < 0.0001) to close by the end of therapy relative to wounds treated with medicinal honey (51% vs 31%, respectively). Finally, VLUs treated with CI were significantly more likely (p < 0.01) to achieve 100% granulation by the end of therapy compared to wounds treated with medicinal honey (36% vs 18%, respectively). CONCLUSION: Over the course of therapy VLUs treated with CI demonstrate greater clinical improvement, particularly total granulation and closure than VLUs treated with medicinal honey.



Adrienne Gilligan, PhD, , Life Sciences, Fort Worth, TX, Marissa Carter, PhD, MA, , Strategic Solutions, Inc, Cody, WY, Curtis Waycaster, PhD, , Market Access, Fort Worth, TX, and Caroline Fife, MD, CWS, , The Woodlands, TX

OBJECTIVE: The objective of this study was to assess the clinical effectiveness of enzymatic debridement with clostridial collagenase ointment (CCO) relative to autolytic debridement with medicinal honey (MH) in the hospital outpatient department (HOPD) setting for the treatment of VLU. METHODS: Retrospective de-identified electronic medical records from 2007 to 2013 were extracted from the US Wound Registry (USWR). The USWR is a longitudinal observation database of chronic wounds from more than 100 HOPD wound centers in the United States. A propensity score matching method was used to adjust for selection bias and to test for treatment effects between wounds treated with CCO versus MH. RESULTS: A total of 9313 patients, 22,312 wounds, and 186,023 visits for VLU were identified. The majority of patients were female (51.9%) with an average age of 61.6 (SD = 17.7). Approximately 21.3% had a history of hypertension, and 8.3% had a history of venous insufficiency with diabetes. Mean baseline wound surface area was 7.9 cm2 (SD = 14.4). The average wound age at baseline was 8.5 months (SD = 27.8) and average treatment duration was 2.9 months (SD = 4.9). Of the 22,312 VLU, approximately 13.2% received CCO (n = 2954) and 2.2% received medicinal honey (n = 495). VLU treated with medicinal honey were significantly more likely (p < 0.0001) to be active and chronic after 60 days relative to wounds treated with CCO (13% vs 9%, respectively). Furthermore, VLU treated with CCO were significantly more likely (p < 0.01) to achieve 100% granulation by the end of therapy compared to wounds treated with medicinal honey (30% vs 19%, respectively). Finally, VLU treated with CCO were significantly more likely (p < 0.0001) to close by the end of therapy relative to wounds treated with MH (45% vs 31%, respectively). CONCLUSION: Over the course of therapy, VLU treated with CCO demonstrate greater clinical improvement with respect to granulation and closure than VLU treated with MH.



Marissa Carter, PhD, MA, , Strategic Solutions, Inc., Cody, WY, Adrienne Gilligan, PhD, , Life Sciences, Fort Worth, TX, Curtis Waycaster, PhD, , Market Access, Fort Worth, TX, and Caroline Fife, MD, CWS, , The Woodlands, TX

OBJECTIVES: The objective of this study was to assess the clinical effectiveness of enzymatic debridement with clostridial collagenase ointment (CCO) as an adjunct therapy to sharp debridement compared to sharp debridement alone for the management of PU in the hospital outpatient department setting. METHODS: Using data sets from the US Wound Registry from 2007 to 2013 at the patient, wound, and visit encounter levels, 3594 PU received CCO and 16,745 PU did not. Applying sharp debridement criteria and propensity score matching resulted in 1074 wounds belonging to each group. Propensity score results showed that characteristics of the group were reasonably matched. RESULTS: Mean patient age was 67-69 years. The majority of the PUs were stage III (56%-59%) with stage IV wounds being the next most common. When PUs were analyzed by PU stage, it was found that the proportion of wounds closed at any time (eg, at 1 year or 2 years) was double for stage IV PU who received CCO compared to those not treated with CCO. Furthermore, Kaplan-Meier analysis showed that time to wound closure at 1 year was significantly faster (and clinically meaningful) for PU treated with CCO versus PU not treated with CCO. When groups were matched by number of CCO applications versus the number of debridements (no CCO) when the number was ≥ 5 (ie, 5 or more CCO applications, or 5 or more debridements and no CCO) the proportion of PU closed at 1 or 2 years was significantly different with more CCO-treated PU being closed than non–CCO-treated PU. CONCLUSION: CCO as an adjunct therapy to sharp debridement yielded better clinical outcomes, providing faster rates of closure for the treatment of stage IV PU relative to sharp debridement alone. Healthcare providers should consider CCO as an effective adjunct therapy to sharp debridement.



Dave Brett, BS, BS, MS, , Clinical Affairs, St. Petersburg, FL

OBJECTIVES: To assess the effectiveness of a formal, year-long HAPU prevention program in the adult intensive care unit (ICU) of our hospital, with a goal of achieving at least a 50% reduction in 2013, compared with 2011. METHODS: Planning for the prevention program began in 2012, and the program was rolled out in the first quarter of 2013. Program components included use of Braden algorithm scores, a revised skin care protocol, fluidized repositioners, and Allevyn Life Silicone Adhesive Dressings (Smith & Nephew, Inc, St. Petersburg, FL). Allevyn Life was used for a Braden Scale score <14 and were encouraged to be used whenever there were pressure points. The most common placement was the sacrum, but dressings were also used on heels, elbows, and under C-collars. Incidence of HAPUs was calculated as the percentage of all patients in the ICU developing a HAPU. Cumulative incidence of HAPU was gathered over a 12-month period following initiation of the protocol. RESULTS: Baseline demographics, including the number of admitted patients and stage of ulcer, are provided in Table 1. Reasons for admission to the adult ICU were varied, with patients having a variety of traumatic injuries, cardiovascular events, and postsurgical complications. Across all years, the majority of HAPUs were stage II. In 2011, prior to beginning the prevention program, there were a total of 45 HAPUs occurring in 9.8% of patients and costing approximately $1.7 million dollars. In 2013, the overall reduction in incidence of HAPUs to 17 (3.0% of patients affected) represented a decrease of over two-thirds (69%) compared with 2011, exceeding our original goal of a 50% reduction. CONCLUSIONS: The convincing results in ICU have led to approval of a hospital-wide roll out of the HAPU prevention program, along with a commitment to ensure that prevention of device-related HAPUs remains a priority.

Department of Health and Human Services. Centers for Medicare & Medicaid Services. SMDL #08-004. July 31, 2008. Accessed December 4, 2014.

National Database of Nursing Quality Indicators. NDNQI Web site. December 4, 2014.

Shreve J, Van Den Bos J, Gray T, et al. The Economic Measurement of Medical Errors. Schaumburg, IL: Society of Actuaries, 2010. Accessed December 4, 2014.

Continence—Complications of Incontinence: Dermatological Issues; Urinary Tract Infection; Renal Deterioration



Donna Z. Bliss, PhD, RN, FAAN, FGSA, , Olga V. Gurvich, MA, , Michelle A. Mathiason, MS, , Kay Savik, MS, , Susan Harms, PhD, RPh, , Jean F. Wyman, PhD, APRN, GNP-BC, FAAN, , and Christine Mueller, PhD, RN, FAAN, FGSA, , School of Nursing, Minneapolis, MN; Lynn E. Eberly, PhD, , and Beth Virnig, PhD, , School of Public Health, Minneapolis, MN

BACKGROUND: Incontinence is common in nursing homes (NHs) but little is known about the prevalence and predictors of prevention of incontinence-associated dermatitis (IAD) there. Reports of racial/ethnic disparities in NH care support examining disparities in IAD prevention. PURPOSE: To determine the prevalence and predictors of IAD prevention in older (65+ years) NH residents with incontinence and assess for racial/ethnic disparities in this care. METHODS: We analyzed data of residents who newly developed incontinence after NH admission but were still free of IAD (n = 10,713) in a cross-sectional design. Residents were 71% female, aged 83 (8) years (mean (SD)), 89% white, 8% black, 1.3% Hispanic, 1.2% Asian, 0.5% American Indian, and in 448 proprietary NHs in 28 states. Approximately 2.3 million practitioner orders were reviewed for reports of IAD prevention. Predictors of IAD prevention were obtained from 4 data sets over 3 years (2000-2002): Minimum Data Set (resident demographics/health), Online Survey, Certification and Reporting (NH staffing/care deficiencies), and US Census (socioeconomic status of NH communities). Predictors of IAD prevention were examined using generalized linear mixed model with random intercepts. Disparities were assessed using the Peters-Belson method. Models provided estimates of the proportion of each minority expected to receive IAD prevention had they been in the White group, which were compared to the proportion observed to receive prevention (z-test); all alpha levels p < .05. RESULTS: 12% of incontinent residents received IAD prevention. There were no disparities in IAD prevention for any minority (p > .05). Predictors of receiving IAD prevention were having greater deficits in activities of daily living (1.02, 1.01-1.03) (OR, 95% CI), more oxygenation problems (1.12, 1.05-1.20), and poorer nutrition (1.20, 1.07-1.33). CONCLUSIONS: The absence of racial/ethnic disparity in IAD prevention in NHs is a positive outcome but IAD prevention is low overall. There is a need for WOC nurses to promote IAD prevention in NHs.



Donna Z. Bliss, PhD, RN, FAAN, FGSA, , Kjerstie R. Wiltzen, BA, BSN, RN, , Alexandra Gannon, , Anna Wilhelms, , and Michelle A. Mathiason, MS, , School of Nursing, Minneapolis, MN; Peggy Bland, RN, HSD, , and Robert Turnbaugh, RN, , Farmington, MO

BACKGROUND: Alkaline skin pH is a risk factor for incontinence-associated skin damage (IASD). A more acidic skin pH reduces risk of IASD and may benefit incontinent adults. PURPOSE: To compare the pH of skin of older (75+ years) incontinent nursing home (NH) residents exposed to an absorbent brief with and without curly fiber wet with an alkaline solution and to various control conditions. METHODS: Using an experimental design, skin pH was measured in duplicate using a pH meter and flat-tipped probe on 6 areas of the right and left inner thighs and 6 areas of the right and left inner forearms; each area was exposed to 1 of 6 conditions, randomly ordered. Experimental conditions: (A) an absorbent brief containing curly fiber wet with an alkaline solution mimicking urine/fecal pH and (B) a wet standard brief (without curly fiber). Control conditions: (C) normal skin, (D) dry brief containing curly fiber, (E) dry standard brief, (F) alkaline solution only. Differences in pH were analyzed using ANOVA; post hoc comparison p values were adjusted using Tukey's test. RESULTS: Twenty-six NH residents (77% female, all white, aged 87 (6) (mean (SD)), 69% with only urinary, 31% with urinary+fecal incontinence) had their skin pH measured. On the thighs, the skin pH (mean (SD)) after A (wet brief+curly fiber) = 5.7(0.5) was less than the pH after B = 6.4 (0.5), C = 6.6 (0.4), D = 6.5 (0.4), E = 6.6 (0.5), and F = 6.4 (0.4). On the forearms, the skin pH after A = 5.3 (0.4) was less than the pH after B = 6.0 (0.4), C = 6.0 (0.5), D = 6.1 (0.6), E = 6.0 (0.4), and F = 5.9 (0.4) (p < .001 for all comparisons to A). No other differences were significant. CONCLUSIONS: Absorbent briefs containing curly fiber significantly lower/acidify pH of skin exposed to an alkaline solution with pH similar to urine/feces while standard briefs do not. Absorbent briefs containing curly fiber have potential to prevent IASD, reduce IASD severity, and promote IASD healing in NH residents.

Ostomy—Stomal/Peristomal Complications



Charu Taneja, MPH, , and Gerry Oster, PhD, , Brookline, MA; Debra Netsch, DNP, APRN, CNP, CWOCN, , and Bonnie Sue Rolstad, RN, MS, CWOCN, , Minneapolis, MN; Gary Inglese, RN, MBA, , Libertyville, IL; Lois Lamerato, PhD, , Detroit, MI

OBJECTIVE: To estimate the risk and economic burden of peristomal skin complications (PSCs) following ostomy surgery in a large integrated US healthcare system. METHODS: Using administrative data, we identified 128 patients who underwent ostomy surgery (colostomy [ICD-9-CM 46.1X], ileostomy [46.2X], cutaneous ureteroileostomy [56.5X], or other external urinary diversion [56.6X]) between January 1, 2008, and November 30, 2012. Based on medical record review, we then identified patients who developed PSCs within 90 days of their surgery. We then examined levels of healthcare utilization and costs over a 120-day period, beginning with the date of surgery, between patients with evidence of PSCs and those without evidence of PSCs, based on information in administrative data stores. Analyses of study data were principally descriptive in nature. RESULTS: Approximately one-third of study subjects (36.7%) had evidence of PSCs in the 90-day period following ostomy surgery, including 7.7% who underwent ileostomy, 35.3% who underwent colostomy, and 43.8% who underwent urinary diversion. Among patients who developed PSCs, mean (SD) time from surgery to first notation of a PSC was 23.7 (20.5) days, ranging from 22.0 (0.0) days for urinary diversion, to 23.2 (20.8) days for colostomy, and 24.2 (21.1) days for ileostomy. Patients with PSCs had longer stays in hospital for the index admission (21.5 days vs 13.9 days for those without evidence of PSCs), and once discharged were more likely to be readmitted to hospital within the observation period (47% vs 33%, respectively). Total healthcare costs over 120 days were almost $80,000 higher among patients with PSCs versus those without evidence of these complications. CONCLUSIONS: Approximately one-third of patients with ostomies develop PSCs within 90 days of their surgery. Costs of care are substantially higher among patients who develop PSCs than they are among those without this complication.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Glenda B. Kelman, PhD, ACNP-BC, , Nursing, Troy, NY, and Mary Anne Jadlos, MS, ACNP-BC, CWON, , Skin, & Ostomy Nursing Service, Troy, NY

Engaging the interprofessional team in a “Zero Tolerance” Facility Acquired Pressure Ulcer (FAPU) Prevention Program Systemwide facilitates commitment, ownership and empowers nurses to “Champion” quality, cost-effective care. Pressure Ulcers (PrUs) are a major health care issue in the United States impacting approximately 3 million adults annually. Facility-acquired pressure ulcer (FAPU) incidence rates range from 0% to 53.4% and US treatment costs range between $37,800 and $70,000/ulcer. The purpose of this study was to investigate facility acquired pressure ulcers (FAPUs) in 2 community hospitals in upstate New York while implementing the “Zero Tolerance” Program. A review of 25 FAPU prevalence studies from 2007 to 2015 was conducted based on 3937 patients in 2 hospitals in upstate New York. A root cause analysis (RCA) was conducted for each FAPU. The FAPU rate for both hospitals ranged from 0.06% to 6.1% during the 8-year period. The average rate of FAPU for the 8-year period was 2.7%, which is lower than the National 2015 FAPU reported rate of 3.6% based on 95,951 patients. The FAPU rate has decreased across both hospitals during the 8-year time period. Root cause analysis revealed common FAPU sites (coccyx, sacrum, and heels) consistent with current national research findings. Limitations included a convenience sample of 2 acute care community hospitals in a multi-institutional health care system. FAPU prevalence data is essential in analyzing rates and trends including root cause analysis (RCA) to improve evidence-based practice in PrU prevention and management, and to reduce costs. In addition, retrospective and concurrent data can be used to establish institutional benchmarks to align with National “Best Practices” to reduce FAPUs. Program interventions include electronic health record (EHR) protocols, documentation, continued quarterly data collection, and analysis of FAPU prevalence and relationships between RCAs, Braden risk scores, and FAPUs.

Agency for Healthcare Research and Quality. Pressure ulcer treatment strategies: comparative effectiveness. Published 2013.

Goldberg M. General acute care. In: Pieper B, ed. Pressure Ulcers: Prevalence, Incidence, and Implications for the Future. Washington, DC: NPUAP; 2012.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific

NYS Gold STAMP Program Pressure Ulcer Resource Guide. Published 2013.

Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media.

Continence—Evidence-Based Treatment and Management



Glenda Motta, BSN, MPH, ET, , GM Associates Inc., Loveland, CO, Catherine T. Milne, APRN, MSN, CWOCN-AP, , Bristol, CT, and Santina Wendling, CCRA, , Clinical Affairs, Mansfield, MA

PURPOSE: Incontinence-associated dermatitis (IAD) is a known risk factor for pressure ulcer (PU) development. In SNFs, >50% of residents are incontinent of either urine or stool.1 METHODOLOGY: A 1-month prospective multicenter, IRB-approved open label convenience sample evaluated IAD prevention and/or improvement in bed, chair-bound or ambulatory residents normally wearing diaper-type briefs. A superabsorbent underpad replaced briefs when the resident was in bed. Change frequency was individualized and the usual skin care regimen followed. Skin integrity and risk for perineal skin breakdown were assessed at baseline and weekly using Perineal Assessment Tool (PAT)2 and scored using IAD Skin Assessment Tool (SAT).3 RESULTS: A total of 40 subjects (n = 31 females; n = 9 males; average age 83) were evaluated. At enrollment, 25 subjects had IAD; 15 did not. Study outcomes were: • Mean PAT Score for 25 subjects with IAD at enrollment decreased from 8.7 to 7.5 at week 4. • Mean IAD SAT score for 25 subjects with IAD at enrollment decreased from 3.3 to 0.7 at week 4. • Subjects with IAD decreased significantly over study duration from 62.5% (baseline) to 37.5% (week 1) (p = 0.0016); 35.0% (week 2) (p = 0.0023); 32.5% (week 3) (p = 0.0005); and 15.4% (week 4) (p < 0.0001). • 15 subjects without IAD at enrollment maintained intact skin from baseline to week 4. • PAT score risk level for 11 of 15 non-IAD subjects decreased from high to low by week 4. • Average cost per day using the superabsorbent underpad was $1.40 versus $2.48 for usual care, primarily due to decreased frequency of pad changes. CONCLUSION: In this study, the use of superabsorbent pads instead of briefs helped reduce IAD in SNF residents with incontinence.

1. Bliss DZ, Zehrer C, Savik K, Smith G, Hedblom E. An economic evaluation of four skin damage prevention regimens in nursing home residents with incontinence: economics of skin damage prevention. J Wound Ostomy Continence Nurs. 1997;24(2):143–152.

2. Nix DH. Validity and reliability of the perineal assessment tool. Ostomy Wound Manage. 2002;48(2):43–49.

3. Lutz JB, Leighton B, Kennedy KL. Comparison of the efficacy and cost-effectiveness of three skin protectants in the management of incontinence dermatitis. Macmillan Magazines LTD. 1997:66–69.

Wound—Evidence-Based Interventions



Heather Duhame, CWCN, NP-C, , Professional Practice, Alexandria, VA

PURPOSE: The purpose of this retrospective study was to evaluate management of suspected deep tissue injury (sDTI) using noncontact low-frequency ultrasound (NLFU) therapy, to compare outcomes of hospital-acquired pressure ulcer (HAPU) versus present on admission (POA) sDTI treated with NLFU therapy, and evaluate ability to successfully treat sDTI located on the heel with NLFU therapy. METHODS: A retrospective chart review was performed evaluating patients treated with NLFU during a 13-month period. Charts in which data were missing or incomplete, patients having sDTI within the base of an existing ulcer, and patients with multiple sDTIs were excluded from this study. RESULTS: Sample size consisted of 44 subjects. Both patients with HAPU sDTI and POA sDTI exhibited a decrease in sDTI size. Mean size in cm2 of injury from initiation to discontinuation of NLFU decreased from 24.6 cm2 to 14.4 cm2. HAPU and POA sDTI exhibited similar percentage of wounds classified as resolved (27% vs. 18%). Mean size of heel sDTIs decreased significantly from 15.9 cm2 to 13.4 cm2 with NLFU therapy. Wounds were classified as resolved at completion of treatment in 23% of all treated patients. Of all patients with the potential to be resolved (ie, not discharged early, died), 63% had wounds classified as resolved (10/16). CONCLUSION: The results of this study suggest that NLFU is a viable and promising treatment option for both HAPU and POA sDTI, as it significantly decreases the size of these injuries. Additionally, heel ulcers displayed decreased size, suggesting that NLFU may also be of benefit to these wounds. Future studies are needed to determine patients in whom this therapy is nonefficacious due to disease state.

Baharestani MM. Suspected deep tissue injuries: an examination of 200 cases. Paper presented at: 41st Annual Conference of Wound, Ostomy, Continence Nurses Society; 2009; St. Louis, MO.

Honaker JS, Forston MR, Davis EA, Wiesner MM, Morgan JA. Effects of noncontact low-frequency ultrasound on healing of suspected deep tissue injury: a retrospective analysis. Int Wound J. 2013;10:65–72.

Braden B. Costs of Pressure Ulcer Prevention: Is It Really Cheaper Than Treatment? National Pressure Ulcer Advisory Panel (NPUAP); 2013.

Ostomy—Stomal/Peristomal Complications



Hsiao Hui Hsu, , Buddhist Tzu Chi General Hospital, Hualien City, Mei-Yu Hsu, , Buddhist Tzu Chi General Hospital, Hualien and Shu-Shang Chang, , Buddhist Tzu Chi General Hospital & Associate Professor, Department of Nursing, Tzu Chi University, Hualien City

PURPOSE: The purpose of this study was to determine the incidence and risk factors of early stoma complications in the postoperative period. METHODS: This was a prospective study conducted at medical center, between January 2014 and September 2015. The data collected including patient demographics, stoma characteristics, and relevant risk factors. The stomal and peristomal complications were assessed each day during and up to 1 month after surgery by wound ostomy and continence nurses. RESULTS: A total of 146 participants were enrolled, most were men (68.5%). The mean age of participants was 63.5 years (SD ±14.7). The incidence of early stoma complications was 53.4%, and 39% occurred within 1 month postoperation. Peristomal skin problem was the most common complication. The risk factors for early stoma complication showed statistical significance included laparoscopic surgery (P < .016), cancer (P < .031), emergency operation (P = .00), and stoma site (P = .00). The analysis of logistic regression proved that emergency operation (OR = 4.93; P = .00) and stoma site (OR = 3.24, P = .39) were effective in predicting the incidence of early stoma complication. CONCLUSION: The research demonstrated that the postoperative stoma complication promptly occurs in the highest rate. The stoma complication is also related to the surgery factors.

Ahmad Z, Sharma A, Saxena P, Choudhary A, Ahmed M. A clinical study of intestinal stomas: Its indications and complications. Int J Res Med Sci. 2013;1(4):536–540. doi:10.5455/2320-6012.ijrms20131140.

Jordan RS, Burns JL. Understanding stoma complications. Published 2013.

Lindholm E, Persson E, Carlsson E, Hallén AM, Fingren J, Berndtsson I. Ostomy-related complications after emergent abdominal surgery: A 2-year follow-up study. J Wound Ostomy Continence Nurs. 2013;40(6):603–610. doi:10.1097/WON.0b013e3182a9a7d9.

Nastro P, Knowles CH, McGrath A, Heyman B, Porrett TRC, Lunniss PJ. Complications of intestinal stomas. Br J Surg. 2010;97(12):1885–1889. doi:10.1002/bjs.7259.

Parmar KL, Zammit M, Smith A, Kenyon D, Lees NP. A prospective audit of early stoma complications in colorectal cancer treatment throughout the Greater Manchester and Cheshire colorectal cancer network. Colorectal Dis. 2011;13(8):935–938.

Wound—Preventative Practices New



Ivy Razmus, PhD, RN, CWOCN, , Wound Ostomy, Tulsa, OK, and Sandra Bergquist-Beringer, PhD, RN, CWCN, , School of Nursing, Kansas City, KS

PURPOSE: Little is known about pressure ulcer risk and prevention practices in hospitalized pediatric patients. The purpose of this study was (1) to describe the frequency of pressure ulcer risk assessment among pediatric acute care patients, as well as methods, and (2) to examine the frequency of pressure ulcer prevention interventions among those at risk overall and by hospital unit type. DESIGN: This was a descriptive secondary analysis of 2012 data on pressure ulcers among pediatric patients from the National Database for Nursing Quality Indicators® (NDNQI®). SUBJECTS AND SETTING: The sample include 39,984 pediatric patients ages 1 day to 18 years of age from 678 pediatric acute care units (general pediatrics, pediatric critical care units, neonatal intensive care units, pediatric step down, and pediatric rehabilitation units) in 271 United States (US) hospitals that submitted pressure ulcer data for at least three quarters during 2012. RESULTS: Most pediatric patients (n = 33,644; 89.2%) received a pressure ulcer risk assessment within 24 hours of admission. The Braden Q Scale was frequently used (56%-86%) to assess pressure ulcer risk on most pediatric units except for NICUs where other scales or other methods were commonly used (55%-60%). Overall, 30% of the pediatric patients (n = 11,203) were at risk for pressure ulcers. The majority (n = 10,741; 95.8%) received some kind of pressure ulcer prevention. Across unit types, nearly all at-risk patients (99.2%) received a skin assessment within the previous 24 hours; 89.5% were repositioned as prescribed, 88.6% had received nutritional support, and moisture was managed for 84.6% of at-risk patients. A pressure redistribution surface was in use for only 70.7% of at-risk patients. CONCLUSION: Most pediatric patients are being assessed for pressure ulcer risk but there is room for improvement in pressure ulcer prevention among pediatric patients.



Ji Yan Lyu, , Hualien, Mei Yu Hsu, , Department of Nursing, Hualien and Shu-Shang Chang, , Buddhist Tzu Chi General Hospital & Associate Professor, Department of Nursing, Tzu Chi University, Hualien City

PURPOSE: The purpose of this study was to investigate incidence of medical devices related pressure ulcers (MDRPU), and to compare the differences in the demographic and wound characteristics among MDRPUs and non-MDRPUs patients. METHODS: A prospective cohort study design was used. From January 2013 to December 2013, all hospitalized patients in a 1000-bed medical center were inspected the patients' skin daily by registered nurses. Data were collected by 2 WOC nurses using structure questionnaires that included demographics and wound status assessment tool. Means, standard deviations, and percentages were used for descriptive purposes. Chi-square test and independent t test were used for dichotomous variables and continuous variables, respectively. RESULTS: Of the total 21,101 patients, 529 (2.5%) patients developed PUs during hospitalization. The proportion of patients with medical devices–related PUs was 27.41% (145 of 529) and the incidence was 0.7% (145 of 21 101). Majority of MDRPUs (59.8%) occurred on the face, head, and neck. 48% MDRPUs were related to respiratory medical device. Most (49.5%) of MDRPUs involved stage II. The mean number of days for wound occurred was 12 (SD = 11.5). The significant variables (p < .05) of difference in MDRPUs and non-MDRPU were location, classification, and division. CONCLUSION: The results of this study provide an outline of MDRPUs that can be used in developing preventive strategies for MDRPUs. They can also be used as a reference for skin tears care curriculum in continuing nursing education.



Jill Cox, PhD, RN, APN, CWOCN, , and Sharon Roche, PhD, RN, APN, CCRN, , Nursing, Englewood, NJ

PURPOSE: This study examined the relationships between type, dose, and duration of 5 vasopressor agents (norepinephrine, vasopressin, epinephrine, phenylephrine, dopamine) and pressure ulcer (PU) development and examined factors that predict PU development in adult critical care patients. BACKGROUND/SIGNIFICANCE: Vasopressor agents are potent vasoconstricting agents used as a life-saving modality to raise mean arterial pressure in shock states. The pharmacodynamics properties intrinsic to these medications suggest they may play a role in PU development; however, this has been understudied in the literature, making it difficult to discern the agent(s) which may pose the greatest risk. METHOD: This study used a retrospective, correlational design. The sample consisted of 306 medical/surgical ICU and cardiovascular adult ICU patients who received vasopressor agents. All data was abstracted from the electronic medical record. Patients who developed PU were compared to those that remained PU free on all study variables using chi-square and t tests. Logistic regression analysis was employed to determine the significant predictors of PU development. RESULTS: Norepinephrine and vasopressin were found to be significantly related to PU development, with vasopressin the only agent to emerge as a significant predictor of PU development in multivariate analysis. Other factors found to be predictive of PU development included cardiac arrest during the ICU admission, longer hours of mean arterial pressure less than 60 mmHg on a vasopressor agent, and mechanical ventilation for longer than 72 hours. CONCLUSIONS: The need to add vasopressin, concomitant with a first-line vasopressor to the treatment plan, may represent a “tipping point” in which PU risk escalates. This may translate for nurses as an early warning to heighten PU prevention strategies. Conversely, as these agents cannot be terminated to avert PU development, this finding may add to the body of knowledge regarding factors that contribute to the development of an unavoidable PU.

1. Edsberg L, Langemo D, Baharestani M, Posthauer M, Goldberg M. Unavoidable pressure injury: state of the science and consensus outcome. J Wound Ostomy Continence Nurs. 2014;41(4):313–334.

2. Manaker S. Use of vasopressors and inotropes. Published 2014.

3. Society of Critical Care Medicine/European Society of Intensive Care Medicine. Surviving Sepsis Campaign. International Guidelines for Management of Severe Sepsis and Septic Shock: 2012.

4. Cox J. Pressure ulcer development and vasopressor agents in adult critical care patients: a literature review. Ostomy/Wound Manage. 2013;59(4):50–60.

Wound—Product Selection and Innovations



Jolene Heil, RN, ET, MClScWH, , Professional Practice, Kingston, ON, and Kevin Woo, PhD, RN, , Nursing, Kimgston, ON

AIM: Increased bacterial burden has been identified as a key factor contributing to delayed wound healing and other serious complications (1). The purpose of this case series is to evaluate a dressing containing methylene blue and gentian violet (MBGV) for the management of chronic wounds that exhibit clinical signs associated with increased bacterial burden. METHOD: Twenty-nine participants between 18 and 85 years of age with a chronic wound of various etiologies (pressure ulcers, diabetic foot ulcers, and surgical wounds) enrolled in the study. Their wounds were evaluated weekly for 4 weeks to determine changes in wound surface area, exudate level, and wound tissue type using the Pressure Ulcer Scale for Healing (PUSH tool) (2). Wound infection was evaluated by the Clinical Signs and Symptoms Checklist (3) that included the following assessment parameters: pain, erythema, edema, heat, purulent exudate, drainage, color, friable granulation tissue, odor, and wound breakdown. RESULTS: Twenty-nine participants completed the study. At baseline, all wounds were documented to have moderate to heavy exudate, foul odor, and devitalized tissue present in the wound bed. The mean PUSH score was 13.27 (SD = 2.15) and mean infection score was 3.55 (SD = 1.09). At the end of week 4, all wounds achieved a granulating wound bed with a mean PUSH score of 10.69 (SD = 2.25) and mean infection score of 0.86 (SD = 0.92). There was a significant improvement in odor and reduction of devitalized tissue (p < 0.001), and in the mean wound size from 21.4 cm2 (SD = 27.6) at baseline to 12.32 cm2 (SD = 18.74) at week 4 according to paired t test (t = 3.07, df = 28, p < 0.005). None of the participants required antibiotic treatment for wound infection during the study. CONCLUSION: Results of this study indicate that the dressing is a suitable option for chronic wounds exhibiting signs of increased bacterial burden as part of an overall wound management plan.

Gardner SE, Hillis SL, Frantz RA. Clinical signs of infection in diabetic foot ulcers with high microbial load. Biol Res Nurs. 2009;11(2):119–128.

Hon J, Lagden K, McLaren AM, O'Sullivan D, Orr L, Houghton PE, Woodbury MG. A prospective, multicenter study to validate use of the PUSH in patients with diabetic, venous, and pressure ulcers. Ostomy Wound Manage. 2010;56(2):26–36.

Woo KY, Alam T, Marin J. Topical antimicrobial toolkit for wound infection. Surg Technol Int. 2014;25:45–52.

Wound—Preventative Practices New



Joshua Menang, RN, , Diabetes, Tiko and Samuel Njimogu, MD, , Administration, Bamenda

BACKGROUND: Developing nations are not left out of the prevailing global diabetes epidemic with foot ulcers featuring as the most common complications. Developing nations, known to shoulder about 75% of the global diabetes burden ( by 2035, is really bad news because resources are often scarce whereas amputations often result from untimely or inappropriate foot wound interventions; leading to independency, decrease productivity, depression, and even a remarkable decrease in quality of life and subsequent death, especially for developing nations. METHODS: A local pilot study, from January 2014 to 2015, isolating 48 diabetic foot ulcer cases from our diabetic record of 98 regular clients—all are type 2; either with ulcer(s) ± wounds. Special assessment using sample cultures, aggressive debridement, neurology tests with specific tools like 10-g monofilaments or Vibratip. Cases were further grouped into a different special care group of neuropathic ulcers for management. RESULTS: Early detection of ulcerations even undetected by the clients had very promising outcome which is further guiding our clinical management approach. Referrals and amputation rates remarkably dropped from 22% in 60 registered diabetes clinic cases to 13%. Despite lack of wound care resources, few available can be of remarkable outcome if adequately improvised. CONCLUSION: Most Cameroonians walk daily to farms, work, businesses, and others. The quality of life in diabetics is threatened by amputations but wound care experts are capable of impacting the outcome greatly by timely and appropriate interventions. There is an urgent need in developing nations, to increase wound professionals and resources; carry more studies and apply vast approaches in preventing a future of handicapped dependent generation as the globe gaze diabetes explosion on the horizon.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Judith Mosier, MS, BSN, RN, CWOCN, , Wound Ostomy Continence Team Methodist, Indianapolis, IN; Joyce Pittman, PhD, CWOCN, , Wound Ostomy Continence, Indianapolis, IN; Kiley Koke, MOT, OTR, and Kathleen Osborn, MS, OTR, , Occupational Therapy Department, Indianapolis, IN

More than 130,000 new ostomies are created annually in North America. Short hospital stays and fragmented follow-up care make it difficult for people with ostomies to obtain needed information and support. Within our organization, we identified missed opportunities to provide interdisciplinary collaboration between wound, ostomy, continence (WOC) team and occupational therapy (OT) for patients with an ostomy. The purpose of this project was to determine if collaboration between WOC team and OT improve the quality of care given to patients with an ostomy in the acute care setting. A retrospective comparative design was used to examine WOC/OT collaboration, length of stay (LOS), readmission rates, and functional status for patients with an ostomy. Our intervention included weekly interdisciplinary collaboration, interdisciplinary education, and development of best practice related to patients with an ostomy. Descriptive analyses were performed. Preintervention, WOC/OT collaboration was nonexistent. Postintervention, weekly interdisciplinary collaboration meetings occurred and 19 patients were identified over 5 months that benefited from this collaboration. Mean LOS improved from 20.26 to 18.39 days, 10% (1.87 days) decrease in LOS. The mean readmission rate for patients with an ostomy was unchanged from 21.43% to 21.43%. OT assessments that addressed ostomy care increased from 1/146 (0.6%) to 33/49 (67%). Postintervention, functional status scores relating to ostomy care improved an average of 2 levels of independence with OT intervention. Interdisciplinary collaboration is essential for patients to receive appropriate and consistent information and care after ostomy surgery. In addition, functional and physical assessment is crucial when developing a comprehensive plan of care. In this study, intentional WOC and OT interdisciplinary collaboration was found to enhance and improve the quality of care given to patients with an ostomy in the acute care setting.

Pittman J, Bakas T, Ellett M, Sloan R, Rawl S. Psychometric evaluation of the ostomy complication severity index. J Wound Ostomy Continence Nurs. 2014;41(2):1–11.

Turnbull G. The ostomy files: ostomy statistics: the $64,000 question. Ostomy Wound Manage. 2003;49(6):22–23. Accessed November 3, 2015.

United Ostomy Associations of America. (2012). Ostomy Information and Care Guides. Accessed November 3, 2015.

Wound, Ostomy and Continence Nurses Society. Management of the Patient With a Fecal Ostomy; Best Practice Guideline for Clinicians. Mount Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.



Paulette Abbas, Kathleen Murphy, BSN, RN, CWON, , Lindsay Stephens, Veronica Victorian, Timothy Lee, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, and Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX

PURPOSE: For improved gastrostomy tube (GT) education, our institution created a standardized educational pamphlet and implemented a formal gastrostomy education course. This study sought to evaluate the impact of this program on emergency room visits and overall cost savings. METHODS: The study included all children who received a surgical GT from 10/2013 to 7/2015. Patients were stratified into preintervention (10/2013-9/2014) or postintervention (10/2014-7/2015). The post cohort was further subdivided into formal education (FE) or standard nursing discharge education through the pamphlet (PE). Unnecessary ED (UE) visits were defined as complications amendable to elective management in clinic or home, such as granulation tissue, dislodgment > 6 weeks, or leakage. Anonymous 5-point Likert scale (5-high understanding to 1-low understanding) surveys were administered to assess impact of FE. RESULTS: A total of 430 patients were in the study. The median age was 13.8 months (IQR 5.0-68.8). Average follow-up for the entire cohort was 222±173 days. When comparing pre- to postpatients, the rate of UE visits (23% vs 11%; p = 0.002) and total number of UE visits (median 1 visit (IQR 1-1) vs 1 visit (IQR 0-1); p = 0.032) decreased, reducing the cumulative direct variable cost associated with the visits ($14616 vs $4644). Seventy-seven patients completed the survey; 13 (17%) had FE. FE significantly improved an understanding of granulation tissue, troubleshooting a clogged port, and minimized uncertainty with GT care. CONCLUSIONS: The implementation of a standardized education protocol improved family understanding of GT care and decreased unnecessary ED visits. Parents appear to have a better understanding of GT care in a formal class setting.

Wound—Dermatological Management/Issues



Kevin Woo, PhD, RN, , Nursing, Kingston, ON, Canada

AIM: Moisture-associated skin damages (MASD) are common and constitute a significant disease burden to patients and the health care system [1]. Moisture-related skin damage is linked to a number of complications including contact irritant/allergic dermatitis, cutaneous fungal/bacterial infection, and pain [1]. The purpose of this cross-sectional study is to determine the effectiveness of cyanoacrylate barrier film for the treatment of painful MASD. METHOD: Data was collected from a convenience sample of 39 patients in a chronic care facility. All participants of the study were between 18 and 85 years of age and they have evidence of MASD. Cyanoacrylate barrier was used for the treatment of MASD for 7 days. All moisture-associated skin damages were evaluated on 5 dimensions, including pain, erythema, maceration, erosion/denudement, and exudation on scales of 0-10; the higher the score the more severe was the clinical presentation. Evaluation was completed on day 0 and day 7. RESULTS: After a 7-day use of cyanoacrylate barrier, significant improvement was noticed in pain (p = 0.05), erythema (p = 0.003), erosion (p = 0.006), and exudate (p = 0.017), according to paired t tests. All superficial lesions improved over time with the treatment of cyanoacrylate barrier film. CONCLUSION: Results of this study indicate that cyanoacrylate barrier film is effective in the treatment of painful lesions associated with MASD.

1. Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurse. 2011;38(3):233–241.

Wound—Management of Complex Wounds



Kimberly LeBlanc, MN, RN, CETN(C), PhD (student), , Nursing, Kingston, ON, Canada, Dawn Christensen, MHSc(N) RN CETN(C), , Enterostomal Therapy, Ottawa, ON, Canada, and Vida Johnston, BScN, RN, WOCN, CAET (C), , Nursing, Ottawa, ON, Canada

Edema is a localized or generalized abnormal accumulation of fluid in body tissues and chronic edema has been directly related to the development of wounds on the lower legs. There is limited published data pertaining to the prevalence of chronic edema in the Canadian Long Term Care (LTC) population. PURPOSE: To explore the prevalence of lower leg edema in the elderly individuals living in Canadian LTC facilities. RESEARCH QUESTIONS:

  • What is the prevalence of edema in individuals living in LTC in Canada?
  • Are healthcare professionals recognizing and diagnosing edema?
  • When edema is recognized and diagnosed, are healthcare professionals implementing measures to minimize or manage edema?

METHODS: A cross-sectional point prevalence study was conducted in an LTC facility in Canada. Descriptive statistics were used to summarize the independent and outcome factors. Pearson's chi-square test was used to test for statistically significant differences between males and females in the prevalence of edema. P value of < .05 was used to indicate statistical significance. RESULTS: A total of 106 residents participated in the study. Age 66-94 years of age (mean = 75). Prevalence of lower leg edema was 63.9%. There was no significance in edema between men and women, 70% were male and 62% female (χ2 = 0.387, p = 0.517). Only 6.4% of those with lower extremity edema were previously identified as having edema (χ2 = .0.039, p = 0.047). None of the individuals identified with edema were receiving compression therapy. CONCLUSION: This study supports the hypothesis that lower leg edema is prevalent in the aging population. Results may not be generalizable due to the small sample size; however, the results highlight the need for further research into the prevalence and impact of lower leg edema in the elderly population living in LTC.

Muldoon J. Managing chronic edema and lymphedema. J Community Nurs. 2011;25(3):41–46.

Wound—Product Selection and Innovations



Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, , Clinical Education, Austin, TX

BACKGROUND: Unrelenting heat, poor sanitation, lack of knowledge, and poverty contribute to disabling wound prevalence that often exceeds 20% in rural areas of tropical developing countries. Wounds in this environment are usually poorly managed at very high cost. Traditional health practitioners and village health workers, rather than health professionals, provide health care in most villages. Wound management education for these nonprofessional health providers should include only sustainable practices which prove to be safe and effective in tropical villages. However, usual practice data, needed for comparison studies, was absent from the published literature. METHODS: This study introduced an innovative data collection method to overcome cultural obstacles which have prevented researchers from obtaining meaningful quantitative data in this challenging setting. UTMB's IRB approved the study. Seventy-five participants from 25 diverse villages in Ghana provided detailed descriptions of their current usual topical wound management methods by completing patient stories representing 7 wound types typically found in this setting, without prompts. STATISTICS: Responses were tabulated and categorized as congruent (or not) with modern topical wound management principles within 3 domains and 6 subcategories. Four research questions were addressed with descriptive statistics and ANOVA. RESULTS: Wound management practices of nonprofessional providers were identified and described in detail for the first time. Most participants described moist treatments, such as bandages or occlusive herbal poultices, regardless of wound type. Safe wound cleansing and debridement were described less consistently. CONCLUSIONS: These results, confirmed by smaller studies in rural areas of other tropical developing countries, provide the usual practice data needed to design a comparison study to help ensure the ecological validity (both safety and efficacy) of wound recommendations for villagers. This research is foundational to the process of developing culturally and environmentally appropriate wound management protocols for indigenous wound care providers in rural areas of tropical developing countries.

Benskin LLL. Discovering the Current wound management practices of rural Africans [dissertation]. Published May 2013. Accessed August 22, 2013.

Professional Practice—Clinical Practice Outcomes; Standards of Care; Clinical Pathways



Mary Lee Potter, MBA, CWOCN, CHRN, , Wound Care Center, San Antonio, TX, and Andrea E. Berndt, PhD, , School of Nursing, Family and Community Health Systems Department, San Antonio, TX

The majority of research examining pressure ulcer (PU) risk factors focus on patients admitted to inpatient hospital settings or nursing homes with few studies focusing on patients in the outpatient hospital settings. The aim of this study was to explore risk factors associated with PU patients admitted to outpatient hospital settings across the nation. Patients with a primary diagnosis of PU who were admitted to an outpatient hospital setting were sampled from the National Hospital Ambulatory Medical Care Survey. Of the 404 identified PU patients included in the sample, the majority were male (52%; n = 210), white (79%; n = 300), and 60 years of age or older (60%; n = 242). Descriptive statistics, independent t tests, and c2 analyses were performed to investigate possible associations between age (59 years or younger vs 60 years or older) and patient characteristics (ie, body temperature, blood pressure, number of comorbidities, number of surgeries, vasopressor use, vascular disease, and diabetes). Patients 60 years of age or older versus those 59 or younger were found to be primarily female and white. The older patients were also found to have more comorbidities, lower diastolic blood pressure, lower body temperatures, and a hypertension diagnosis. These findings were similar to other findings from inpatient settings suggesting that some PU patient characteristics are consistent across clinical settings.

Alderden J, Whitney JD, Taylor SM, Zaratkiewicz S. Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: A retrospective review. Crit Care Nurse. August 2011;31(4):30–42.

American Diabetes Association. Published 2015.

Bergstrom N, Braden B, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nurse Res. 1987;36(4):205–210.

Black J, Girolami S, Woodbury MG, et al. Understanding pressure ulcer research and education needs: a comparison of the association for the advancement of wound care pressure ulcer guideline evidence levels and content validity scores. Ostomy Wound Manage. November 2011;57(11):22–35.

Brem H, Maggi J, Nierman D, et al. High cost of stage IV pressure ulcers. Am J Surg. October 2010;200(4):473–477.

Bryant RA, Nix DP. Acute & Chronic Wounds Current Management Concepts (4th ed.). St. Louis, MO: Elsevier Mosby; 2012.

Coleman S, Gorecki C, Nelson EA, et al. Patient risk factor for pressure ulcer development: Systematic review. Int J Nurs Stud. 2013;50:974–1003.

DeLaune SC, Ladner PK. Fundamentals of nursing: standards & practice. [eBook collection (EBSCOhost)].×[email protected]&vid=0&format=EB&lpid=lp_77&rid=0. Published 2002.

Delmore B, Lebovits S, Suggs B, Rlnitzky L, Ayello E. Risk factors associated with heel pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs. May/June 2015;42(3):242–248.

Demarre L, Verhaeghe S, Van Hecke A, Clays E, Grypdonck M, Beckman D. Factors predicting the development of pressure ulcers in an at risk population who receive standardized preventive care: secondary analyses of a multicentre randomized controlled trial. J Adv Nurs. 2015;71(2):391–403.

Dugaret E, Videau M, Faure I, Gabinski C, Bourdel-Marchasson I, Salles N. Prevalence and incidence rates of pressure ulcers in an emergency department. Int Wound J. October 8, 2012;11(4):386–391.

Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (2nd ed.). Perth, Australia: Cambridge Media; 2014.

IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.

Man S, Au-Yeung T. Hypotension is a risk factor for new pressure ulcer occurrence in older patients after admission to an acute hospital. JAMDA, 2013;14:627.e2–627.e5.

Messer M. Pressure ulcer risk in ancillary services patients. J Wound Ostomy Continence Nurs. March/April 2010;37(2):153–158.

Pokorny ME, Rose M, Watkins F, Swanson M, Kirkpatrick MK, Wu Q. The relationship between pressure ulcer prevalence, body mass index, and Braden scales and subscales: a further analysis. Adv Skin Wound Care. 2014;27(1):26–30.

Press Ganey website. Published 2015.

Slowikowski GC, Funk M., Factors associated with pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs. November/December 2010;37(6):619–626.

Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon J, Mason S. (,). Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs. March 2007;57(5):494–504.

Tescher AN, Branda ME, Byrne TJ, Naessens JM.). All at-risk patients are not created equal. J Wound Ostomy Continence Nurs. May/June 2012;39(3):282–291.

The Centers for Medicare & Medicaid Services website. Published 2014.

Tschannen D, Bates O, Talsma A, Guo Y. Patient-specific and surgical characteristics in the development of pressure ulcers. Am J Crit Care. March 2012;21(2):116–125.

US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey. doi:10.3886/ICPSR29922. Published 2008.

Vesley R. The great migration. Hosp Health Netw. March 11, 2014.

Ostomy—Clinical Outcomes



Mitsuko (Ishii) Okuizumi, , Tokyo, Japan

PURPOSE: The purpose of this study, skin barrier function, and a microscope were used to multilaterally examine the condition of peristomal skin. METHODS: Wound, ostomy and continence nurses (WOC nurses) examined the subjects for patient demographic data and skin care method, type of appliance, presence/absence of skin damage, and skin barrier function. To evaluate skin barrier function, transepidermal water loss (TEWL) and skin hydration were measured at 2 sites (peristomal skin barrier site and normal skin site). A microscope was also used to obtain the images of these measurement sites. RESULTS: There were 27 subjects, including colostomy (n = 18), urostomy (n = 5), and ileostomy (n = 4). Their mean age was 70.7 ± 9.2 years. The mean TEWL was 4.5 ± 2.9 g/m2/h at the normal skin site, and 8.0 ± 5.7 g/m2/h at the peristomal site, indicating a significant difference (p <0.001). According to the data by appliance, the mean TEWL was 7.5 ± 4.6 g/m2/h in Group A (the skin barrier not containing SIS), 11.3 ± 8.0 g/m2/h in Group B (the skin barrier containing SIS), and 5.6 ± 2.7 g/m2/h in Group C (the skin barrier containing ceramide). Although the mean TEWL in Group C was the lowest. The TEWL at the peristomal site was correlated with the period after stoma creation (the number of months) and the intervals of change of appliances (r =0.44,p = 0.02;r =0.49,p = 0.009). In the comparison between the microscopic image of normal skin and that of peristomal skin, more remarkable disappearance and reduction of cristae cutis and sulci cutis were confirmed in the latter image. CONCLUSION: Decrease in skin barrier function was observed in patients with stoma for a long time or depending on the method and the type of appliance. The results suggest that deteriorating peristomal skin needs to be treated with special care.

Erwin-Toth P, Doughty D. Principles and procedures of stomal management. In: Hampton B, Bryant R, eds. Ostomies and Continent Diversions: Nursing Management. St. Louis, MO: Mosby; 1992:29–103.

Rolstad BS, Erwin-Toth PL. Peristomal skin complications: Prevention and management. Ostomy Wound Manage. 2004;50(9):68–77.

Continence—Complications of Incontinence: Dermatological Issues; Urinary Tract Infection; Renal Deterioration



Raha Been, PhD, , Patrick Parks, MD, PhD, , Bruce Ekholm, MS, , Tanya Beckwith, , Stéphanie Bernatchez, PhD, , Anila Prabhu, PhD, , and Robert Asmus, MS, , Critical & Chronic Care Solutions Division, St. Paul, MN

A porcine model was used to test a new therapy for patients who suffer from incontinence-associated dermatitis or general loss of skin integrity. The objective was to evaluate the process of reepithelialization in the continued presence of simulated incontinence fluid. Seven Yorkshire pigs were prepped for sterile field surgery. On each pig, 10 partial thickness wounds (2 × 2 in) were created using a dermatome set to 0.5-mm thickness (5 on each side of the spine). Pressure was applied for 5 minutes with a gauze pad to reduce drainage. Treatments were applied in a randomized fashion, using 35 sites for the control group (uncoated) and 35 sites for the treatment (coated with the new barrier film). The film was allowed to dry for 5 minutes. The wounds were challenged with simulated incontinence fluid (pancreatin in alkaline solution, pH 9) using an occlusive patch test system and then covered with a foam dressing. After 96 hours, samples were excised from each wound for histological evaluation of reepithelialization. Data was analyzed using a mixed model analysis of variance, with treatment group as a fixed factor in the analysis, and pig and pig-by-treatment group as random factors. The percentage of reepithelialization was significantly greater for the wounds covered with the new barrier film than for the control wounds (p = 0.003; on average, 18.3% greater, with a 95% confidence interval of 9.2% to 27.5%). Treated wounds had consistent, continuous, long stretches of reepithelialized epidermis frequently displaying elongated rete pegs similar to native epidermis. Control wounds had inconsistent, less linear, and more disorganized epidermis as well as foreign material from the patch. In this experiment, the new barrier film provided an environment for reepithelialization to occur in the continued presence of a simulated incontinence fluid over a period of 96 hours and protected wounds from debris.



Raha Been, PhD, , Patrick Parks, MD, PhD, , Bruce Ekholm, MS, , Tanya Beckwith, , Stéphanie Bernatchez, PhD, , Anila Prabhu, PhD, , and Robert Asmus, MS, , Critical & Chronic Care Solutions Division, St. Paul, MN

A porcine model was used to test a new therapy being designed for patients who suffer from incontinence-associated dermatitis or general loss of skin integrity. The objective of this study was to demonstrate the efficacy of a new barrier film in helping control minor bleeding and exudate compared to untreated wounds in an animal model. Six Yorkshire pigs were prepped for sterile field surgery. On each pig, 10 partial-thickness wounds (2 × 2 in) were created using a dermatome set to 0.5-mm thickness (5 on each side of the spine). Pressure was applied for 2 minutes with a gauze pad to reduce drainage. Treatments were applied in a randomized fashion, using 12 sites for the control group (uncoated) and 48 sites for the treatment (coated with the new barrier film). Wounds were allowed to dry for 5 minutes to ensure the treatment group was dry. Wound exudate was measured by collecting and weighing fluid from wounds immediately postcreation and after 96 hours. Postwound creation, wounds treated with the new barrier film produced an average of 0.083 g of wound fluid compared to 0.238 g for untreated wounds (2.9 times more fluid for untreated wounds). All wounds were then covered with a foam dressing. After 96 hours, wounds treated with the new barrier film had produced an average 2.231 g of additional wound fluid compared 4.328 g for untreated wounds (1.9 times more fluid for untreated wounds). The difference between treatment groups was statistically significant at both time points (ANOVA test; p = 0.001). This experiment demonstrated that a single application of the new barrier product successfully attached to intact periwound skin and to denuded, weepy skin. This product significantly reduced the amount of fluid weeping from the wounds and continued to perform throughout a 96-hour experiment.



Raha Been, PhD, , Patrick Parks, MD, PhD, , Deena Conrad-Vlasak, MS, CCRA, , Bruce Ekholm, MS, , Tanya Beckwith, , Stéphanie Bernatchez, PhD, , Anila Prabhu, PhD, , and Robert Asmus, MS, , Critical & Chronic Care Solutions Division, St. Paul, MN

A guinea pig model was used to test a new barrier film being designed for patients at risk for incontinence-associated dermatitis or general loss of skin integrity. The objective of this study was to evaluate the barrier efficacy of a new product in protecting intact skin from irritation due to a caustic irritant. The test method used hairless guinea pigs and a simulated incontinence exposure. Six 1.5-by-1.5 inch sites on each back (intact skin) were marked. Five were treated with the new barrier and one left untreated as a control. The treatment was allowed 5 minutes to dry. All sites were then challenged with a solution of pancreatin in alkaline solution (pH 9) using an occlusive patch test system, covered with a custom-cut transparent film dressing, and followed for 48 hours. At 48 hours, the skin irritation of each site was scored. The amount of irritation was measured as a percentage of the 25-mm round area of challenge given by the occlusive chamber. The level of irritation was given a score of 1-4 based on the Clinician Erythema Assessment scale.1 All the sites were given a score by multiplying the level of irritation by the percent irritation to provide a normalized irritation score. The scores were compared using an analysis of variance (ANOVA) with Guinea pig as a random effect and formula (new barrier or untreated) as a fixed factor in the model. The average normalized irritation score was 0.2 for the new barrier and 1.7 for the control (p < 0.001). The untreated sites had therefore 8.5 times more irritation than sites covered with the new barrier film. This experiment demonstrated that a single application of the new barrier can prevent skin breakdown from a caustic irritant and provide protection for at least 48 hours in this model.

Tan J, Liu H, Leyden JJ, Leoni M. Reliability of Clinician Erythema Assessment Grading Scale. J Am Acad Dermatol. 2014;71:760–763.

Wound—Management of Complex Wounds



R. Gary Sibbald, BSc, MD, FRCPC, (Med, Derm), MACP, FAAD, MEd, FAPWCA, , University of Toronto, Toronto, ON, Canada; Patricia Coutts, RN, , Wound healing Center, Toronto, ON, Canada; James Elliott, MSc, BSc, , and Reneeka Persaud, MD, IIWCC Canada, , Mississauga, ON, Canada

BACKGROUND AND AIMS: Pilonidal sinus is a cyst or abscess near or on the natal cleft of the buttocks.1 This study examined patients with stalled and difficult-to-close pilonidal sinuses in a clinic based in Mississauga, Canada. The study aimed to assess the impact of polymeric membrane silver rope cavity filler, used with debridement, hair removal, and systemic antibiotics. The polymeric membrane silver rope cavity filler wound dressing is designed for use in tunnels, where it has been designed to facilitate an inflammatory response into the primary site of injury and reduce the spread of swelling into the surrounding tissues.2,3 METHODS: Polymeric membrane silver rope cavity filler was inserted into the sinuses. Secondary dressings included dry gauze, silicone tape, and sanitary napkin/pad. RESULTS: In total, 16 patients (13 male, 3 female) presented with an open wound at their initial visit. Of these, 94% (n = 15) had at least 1 prior surgical intervention. At initial assessment, average patient age was 23 (16-49). Mean pain score was 3.4 (0-10 scale); 94% (n = 15) of wounds were classified as healable and 6% (n = 1) were maintenance. Mean wound surface area was 3.3 cm2 (range: 0.2-19.6 cm2). Based on NERDS criteria, 63% (n = 10) were critically colonized.4 Based on STONEES criteria, 88% (n = 14) met criteria for deep infection.4 At the second visit, 37% (n = 6) of the pilonidal sinus wounds were closed. By the final visit, 68% (n = 11) were closed. Longest evaluation period was 6 visits. An additional 12% (n = 2) were smaller at the final visit, along with 12% (n = 2) that were larger in size; one case (6%) had no follow-up visit. CONCLUSIONS: Use of polymeric membrane silver rope cavity filler, combined with expert clinic diagnosis and comprehensive treatment, leads to successful wound healing outcomes in 80% of patients with stalled and difficult-to-close pilonidal sinuses.

1. Klass AA. The so-called pilo-nidal sinus. Can Med Assoc J. November 1, 1956;75(9):737–742.

2. Beitz AJ, Newman A, Kahn AR, Ruggles T, Eikmeier L. A polymeric membrane dressing with antinociceptive properties: analysis with a rodent model of stab wound secondary hyperalgesia. J Pain. February 2004;5(1):38–47.

3. Kahn AR, Sessions RW, Apasova EV. A superficial cutaneous dressing inhibits pain, inflammation and swelling in deep tissues. Poster Presented at World Pain Conference; July 15-21, 2000.

4. Woo KY, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage. August 2009;55(8):40–48.

Wound—Product Selection and Innovations



Samantha Westgate, , Hannah Thomas, , and Rebecca Booth, , Cheshire; Jodie Lovett, MEng, , and Christian Stephenson, BSc, , Research and Development, Knutsford

INTRODUCTION: The presence of methicillin-resistant Staphylococcus aureus (MRSA) within chronic wounds poses a risk to the patient and surrounding patients/carers. Sequestration of MRSA in a dressing could improve the infection status of the wound bed and decrease the risk of MRSA transmission. This study assesses MRSA sequestration in superabsorbent (SAP) dressings following absorption. METHODS: Five different SAP dressings were assessed over 7 days compared to knotted gauze. Dressings (n = 12) were placed on top of 15 ml of MRSA inoculum containing 106 cfuml−1. 15 mL of inoculum was added daily for 7 days to simulate a highly exuding wound. On days 1, 3, and 7, dressings were transferred to agar plates and incubated overnight at 37°C. Dressings were then removed and the plates photographed for evidence of MRSA transfer from the dressing. Samples of the inner material of each dressing were processed and remaining viable bacteria quantified. Additional samples of the inner core were fixed and visualized using environmental scanning electron microscopy (ESEM). RESULTS: Each dressing was able to uptake the full volume of MRSA inoculum supplied over the 7 days. The Gauze control was unable to handle the fluid. Subsequently, the SAP dressings retained significantly more bacteria than gauze (average 1 log improvement) (p < 0.001). One dressing demonstrated a 4 log improvement in bacterial retention. On transfer to agar, a range of bacterial transfer was seen, some dressings demonstrated little to no transfer with others allowing growth at each time point. ESEM imaging showed 1 dressing contained no viable MRSA, 3 displayed MRSA on the surface, and 1 held MRSA beneath the gelling agent. CONCLUSION: A range of sequestration abilities were observed throughout the test. All SAP dressings demonstrated an improvement over gauze. One dressing demonstrated increased sequestration, displaying no viable bacteria on ESEM imaging, and a 4 log improvement over gauze.

Wound—Preventative Practices New



Sandy Quigley, RN, MSN, CWOCN, CPNP, , Children's Hospital Boston, Boston, MA; Lindyce Kulik, RN, MS, CWON, CPNP, CCRN, , Cardiovascular Critical Care, Boston, MA; Margaret McCabe, PhD, RN, PNP, , Nursing, Boston, MA; Catherine Noonan Caillouette, RN, MS, CPNP, CWOCN, , Plastic Surgery, Boston, MA; Rosella Micalizzi, MSN, RN, CPNP-PC, , and Jane Murphy, MS, RN, PPCNP-BC, CPHQ, , Pediatric Surgery, Boston, MA; Susan Hamilton, RN, MS, CCRN, CWOCN, , Nursing Critical Care, Boston, MA; Sarah Wells, MSN, RN, CPN, CWOCN, , Complex Care Service, Boston, MA; Caroline Costello, MBA, BSN, RN, CPON, BMTCN, , Hematopoietic Stem Cell Transplant Program, Boston, MA; Janelle Nobrega, MSN, RN, CPNP, , Inpatient Cardiovascular Program, Boston, MA; Natalie Hasbani, MPH, , Cardiology, Boston, MA; Martha A.Q. Curley, RN, PhD, FAAN, , School of Nursing, Philadelphia, PA

PURPOSE: Hospital-acquired pressure ulcers (HAPUs) from immobility and medical devices represent serious iatrogenic injury in acute care environments. The first step in pressure ulcer (PU) prevention is accurate risk assessment. A free-standing academic medical center in the northeast collected comprehensive prospective data to describe pediatric patients at risk to develop PUs. Our data will be combined with 7 other pediatric hospitals to complete a multicenter study testing the predictive validity of the (1) Braden Q Scale for development of immobility-related pressure ulcers and (2) Braden Q+D Scale for development of medical device-related pressure ulcers in pediatric patients. METHODOLOGY: Nursing units were screened using a randomization sequence. To ensure an adequate sampling of at-risk groups across the organization, subject enrollment was stratified by age group and patient type (medical/surgical and cardiac). After obtaining informed consent 2 separate teams of nurses, blinded to each other's assessments, worked in tandem to assess risk and presence of PUs. All PUs were staged by a CWOC nurse and photographed. Interrater reliability between the 2 teams of nurses was established prior to the start of data collection and rechecked regularly during data collection. RESULTS: From 04/09/2013 through 07/24/2015, our site screened 2974 subjects to enroll a stratified sample of 123 subjects, 24 developed 49 PUs, 34 were medical device-related, and 15 immobility-related. Ten patients had more than 1 ulcer. Median Braden Q score on admission was 20 (18-24). The majority of PUs were Stage I (24) and II (16). The 3 devices most frequently associated with PUs at our center were O2 Sat probe, OTT, BiPAP/CPAP. CONCLUSION: These descriptive findings contribute new knowledge about PU development in acute care pediatrics and will make an important contribution to the science of predicting device and immobility related risk for PUs in acute care pediatric populations.

Quigley S. Chapter 22—Pressure ulcers in neonatal and pediatric populations. In: Baranoski S, Ayello E, eds. Wound Care Essentials: Practice Principles, 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2015.

Murray J, Quigley S, Curley M, Noonan C. Medical device-related hospital acquired pressure ulcers in children: an integrative review. J Pediatr Nurs. November-December 2013;28:585–595.

Noonan C, Quigley S, Curley MAQ. Using the Braden Q Scale to predict pressure ulcer risk in pediatric patients. J Pediatr Nurs. 2011;26(6):566–575.

Black J, Cuddigan J, Walko M, Didier L, Lander M, Kelpe M. Medical device related pressure ulcers in hospitalized patients. Int Wound J. 2010;7:358–365.

Curley M, Quigley S, Lin M. Pressure ulcers in pediatric intensive care: incidence and associated factors. Pediatr Crit Care Med. 2003;4(3):284–290.

Wound—Psychosocial and Quality of Life Aspects



Teresa J. Kelechi, PhD, RN, CWCN, FAAN, , Medical University of South Carolina, College of Nursing, Charleston, SC, Martina Mueller, PhD, , Medical Univ of South Carolina, College of Nursing, Charleston, SC, and Mary Dooley, MS, , College of Nursing, Charleston, SC

PROBLEM: The burden of symptoms associated with chronic venous disease (CVeD) is poorly understood, underrecognized, and ill-managed. Symptom research is central to tailoring effective treatments and improving health. PURPOSE: To determine whether there are differences in leg symptoms and symptom clusters between men and women with CVeD. METHODS: Data were collected at baseline from 264 patients, with an 11-item VEINES-SYM questionnaire, enrolled in a randomized clinical trial that examined cooling pack applications to prevent venous leg ulcers. Symptom clusters were defined as 3 or more concurrent symptoms that occurred at least weekly. ANALYSIS: An intrinsic scoring algorithm was used to calculate overall scores for each item by sex. Exploratory factor analysis identified symptom clusters (factors) using oblique rotation to account for correlations between factors. RESULTS: Average age was 61.7 years; 54.5% female, 58% African American or black, 60.6% had diabetes. Top 3 symptoms for women in order of frequency: achy legs, swelling, and pain; for men, swelling, achy legs, and heavy legs. For the total group, 2 symptom clusters, Distressful and Discomfort, were noted. No statistically significant differences were observed in factor scores between females and males. For sex, different factor loadings for symptom clusters were observed; females reported Hurting and Annoying clusters; males, Nagging and Irritating. DISCUSSION: Findings suggest differences in CVeD symptoms and clusters by sex. The symptoms in each of the 2 clusters differed; however, consistency was noted in the factors associated with each. Two clusters in each group were characterized by neuropathic type symptoms (Hurting and Nagging), the other (Annoying and Irritating) were nocioceptive in nature. Comorbid conditions (diabetes) and sex differences in pain responses may play a role in the presentation of symptoms. This study supports the need for increased sex-delineated clinical assessment and consideration of potential differences required in the management of CVeD symptoms.

Do HT, Edwards H, Finlayson K. Identifying relationships between symptom clusters and quality of life in adults with chronic mixed venous and arterial leg ulcers [published online ahead of print 2015]. Int Wound J. doi: 10.1111/iwj.12405.

Edwards H, Finlayson K, Skerman H, et al. Identification of symptom clusters in patients with chronic venous leg ulcers. J Pain Symptom Manage. 2014;47(5):867–875.

Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vascular Surg. 2003;37(2):410–419.

Lohr JM, Bush RL. Venous disease in women: epidemiology, manifestations, and treatment. J Vascular Surg. 2013;57(4) (suppl):37S–45S.

Wellborn J, Moceri JT. The lived experiences of persons with chronic venous insufficiency and lower extremity ulcers. J Wound Ostomy and Continence Nursing. 2014;41(2):122–126.

Wound—Management of Complex Wounds



Vera Lúcia C. G. Santos, PhD, MSN, BSN, CWOCN, (TiSOBEST, Brazil), , Medical-Surgical Nursing Department, São Paulo, Brazil, Giovana R. P. Peres, BSN, MSN, , São Paulo, Brazil, and Kelly C Strazzieri-Pulido, BSN, MSN, , São Paulo, Brazil

AIM: Identify and analyze the prevalence of skin tears (ST) and demographic and clinical factors associated with its occurrence in institutionalized elderly. METHOD: Epidemiological cross-sectional analytical, exploratory study performed in 3 nursing homes of São Paulo. Data were collected by records consultation, interview with the resident and/or care giver, and physical examination of the elderly. The following tools were used for data collection: sociodemographic and clinical data, Mini Mental State Examination test, Katz index, and STAR Classification System. Data were analyzed using Fisher's test, Wilcoxon-Mann-Whitney test, and logistic regression (backward stepwise). RESULTS/DISCUSSION: The sample of 69 residents was mostly composed by women (51/73.91%), Caucasians (50/72.46%), mean age 81 (SD = 9.30), and median 82 years old, some problem in mobility (gait) (58/84.06%), visual acuity problems (56/81.16%), dependence for activities of daily living (52/75.36%), cognitive impairment (51/73; 91%), presence of incontinence (45/65.22%) and some degree of malnutrition (underweight = 26/37.69%). Eight subjects had 13 ST, resulting in an overall prevalence of 11.6%, and 22.22% for men, 7.84% for women and 10.00% for the Caucasians. Eleven (84.6%) STs were located in the lower limbs, predominantly category 3 ST (6/46.1%). The presence of hematoma (RC: 9159; p = 0.017) and senile purpura (RC: 6265; p = 0.033) remained after logistic regression analysis. CONCLUSION: The prevalence of ST among institutionalized elderly was 11.6% and the factors associated are hematoma and senile purpura.

1. Payne R, Martin M. The epidemiology and management of skin tears in the older adult. Ostomy/Wound Manage. 1990;26(Jan/Feb):26–37.

2. Carville K, Lewin G, Newall N, et al. STAR: A consensus for skin tear classification. Primary Intent. 2007;15(1):8–25.

3. Pulido KS, Santos VLCG. Cultural adaptation and validation of STAR Skin Tear Classification System for Brazilians. J Wound Ostomy Continence Nurs. 2011;38(3S):S92.

4. LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9):2–15.

5. West Wound prevalence survey 2011. State Wide Overview Report. Disponível em: Accessed August 2014.

Professional Practice—Role Justification Issues: Data Collection; Cost/Benefit Studies; CQI Programs Specific to the WOC(ET) Nurse Scope of Practice



Flavia Firmino Sr., Oncologist Stomatherapy Nurse, , Palliative Care service, Rio de Janeiro, Laisa Alcântara, Oncologist Nurse, , Emergency Service, Rio de Janeiro, and Vera Lúcia C. G. Santos, PhD, MSN, BSN, CWOCN, (TiSOBEST, -, Brazil), , Nursing College of the University of São Paulo, São Paulo, Brazil

INTRODUCTION AND AIMS: In Brazil, the National Cancer Institute found that about 20% of women affected by breast cancer who are treated in its palliative care unit have malignant fungating wounds. Research on this type of wounds is still scarce in the international literature. However, these wounds are impacting negatively on the quality of life of patients, and the complexity of its topical therapy raises doubts among nurses and high costs for the health system. This study aimed to identify the perceptions of nurses who come to the topic of care malignant wounds in women with breast cancer. METHODS: This is an observational study, descriptive, qualitative approach which used the focal group strategy, interview if applying semistructured. Five nurses working in Wound Care Clinic Ambulatorial participated in the study, after approval by the Ethics Committee Research of the institution under protocol number CEP 132/09. Data analysis was performed by categorizing Bardin. RESULTS: After analyzing the interviews, we observed the formation of 3 categories: clinical practice as subspecialty oncologist nurse; formation of bonds (patient-nurse) in the ambulatory space; malignant fungating wound as disfigurement of the body and women's self-esteem and challenging and frustrating care for nurses, notes that contribute for care nursing practice. CONCLUSION: It was concluded that there is a need for increased expertise in oncological nursing on malignant neoplastic wounds and palliative care, including conducting interactive group research, the possibility of early realization of hygienic mastectomy, professional involvement, technical skill, autonomy, and collaborative work with the health team for the best performance of the nurses in favor of their patients.

Alexander SJ. An intense and unforgettable experience: the lived experience of malignant wounds from the perspectives of patients, caregivers and nurses. Int Wound J. 2010;7:456–435.

Brasil Ministry of Health. National Cancer Institute. Indicators of the Palliative Care Unit/Cancer Hospital IV. Rio de Janeiro: INCA; 2009.

Grocott P, Gethin G, Probst S. Malignant wound management in advanced illness: new insights. Curr Opin Support Palliat Care. 2013;7(1):101–105.

Lo S-F, Hayter M, Hu W-Y, Tai C-Y, Hsu M-Y, Wu L-Y. Symptom burden and quality of life in patients with malignant fugating wounds. J Adv Nurs. 2011; 68(6):1312–1321.

Probst S, Arber A, Faithfull S. Malignant fungating wounds: a survey of nurses' clinical practice in Switzerland. Eur J Oncol Nurs. 2009;13:295–298.

Ostomy—Psychosocial and Quality of Life Aspects



Xin Zhou, , Urology Surgery, Kunming and Qiongyao Guan, , Nursing Department, Kunming

OBJECTIVE: This study aims to investigate the correlation between social relational quality and hope among patients with bladder cancer treated by urinary diversion abdominal ostomy. METHODS: Forty-six bladder cancer patients who were treated by urinary diversion abdominal ostomy were enrolled in this cross-sectional descriptive study. They were investigated with the Social Relational Quality scale (SRQs) and Herth Hope Index (HHI). RESULTS: The total scores of social relationship quality and hope were 49.42 ± 4.98 and 38.52 ± 4.64, respectively. Scores of the total scale and the factors of social relationship quality and hope were positively correlated (r = 0.324-0.680). CONCLUSION: Positive correlation exists between social relational quality and hope among patients with bladder cancer who were treated by urinary diversion abdominal ostomy. It is suggested to give the patients hope and encourage their families to provide more support for better acceptance and adjustment.

1. Parkin DM, Bray F, Ferlay J. Global cancer statistics, 2002. Cancer J Clin. 2005;(02):74–108.

2. Popek S, Grant M, Gemmill R. Overcoming challenges: life with an ostomy. Am J Surg. 2010;(05):640–645.

3. Borwell B. Rehabilitation and stoma care: addressing the psychological needs. Br J Nurs. 2009;(4) (suppl):S24–S25.

4. Hou WK. Psychosocial Resources and Adaptation Among Chinese People With Colorectal Cancer. Hong Kong: The University of Hong Kong; 2008.

5. Lai JCL, Cheung H, Lee WM. The utility of the revised Life Orientation Test to measure optimism among Hong Kong Chinese. Int J Psychol. 1998;45–56.

6. Liu CP, Leung DS, Chi I. Social functioning, poly-pharmacy and depression in older Chinese primary care patients. Aging Mental Health. 2011;(06):732–741.

7. Hou WK, Lam WW, Law CC. Measuring social relational quality in colorectal cancer: the Social Relational Quality Scale (SRQS). Psycho-oncology. 2009;(10):1097–1105.

8. Phillips-Salimi CR, Haase JE, Kintner EK. Psychometric properties of the Herth Hope Index in adolescents and young adults with cancer. J Nurs Measure. 2007;(01):3–23.

9. Carstensen LL. Social and emotional patterns in adulthood: support for socio-emotional selectivity theory. Psychol Aging. 1992;(03):331–338.

10. Ho RT, Chan CL, Ho SM. Emotional control in Chinese female cancer survivors. Psycho-oncology. 2004;(11):808–817.

11. Smith DM, Loewenstein G, Jankovic A. Happily hopeless: adaptation to a permanent but not a temporary, disability. Health Psychol. 2009;(06):787–791.

12. Denewer A, Farouk O, Mostafa W. Social support and hope among Egyptian women with breast cancer after mastectomy. Breast Cancer(AUCKI). 2011;93–103.

13. Khan A, Husain A. Social support as a moderator of positive psychological strengths and subjective well-being. Psychol Rep. 2010;(02):534–538.

14. Slade DL. The voice of experience. J Wound Ostomy Continence Nurs. 2000;(04):201–206.

15. Simmons KL, Smith JA, Bobb KA. Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships. J Adv Nurs. 2007;(06):627–635.

Wound—Management of Complex Wounds



Xiaohong Meng, and Xiuqun Yuan, , Shanghia

PURPOSE: To evaluate the effect of the early use of hydrocolloid versus traditional gauzes to prevent fat liquefaction after radical cystectomy. METHODS: A retrospective study was undertaken between May 2014 and May 2015. After radical cystectomy, 45 patients were randomized to either hydrocolloid (n = 24) or gauzes (n = 21) to promote abdominal wound healing. Outcomes included the comparison of exudates of the incision and patients' pain for dressing changing after 3, 6, and 9 days after the surgery. Wound outcomes, wound complications, times of dressing changing, expenses, and length of stay were compared at discharge. Statistical analysis: All data was analyzed with SPSS software (version 20.0). Continuous data were compared with nonparametric Wilcoxon test or 2 independent-samples t test, if appropriate. P < 0.05 was deemed statistically significant. RESULTS: All results of applying hydrocolloid demonstrated positive outcomes than gauze changing (P < 0.05), especially on controlling exudates on the 6th day after surgery when the incision had the largest amount of exudates (P = 0.004). Four wounds had fat liquefaction and one wound had infection after the use of hydrocolloid, compared with 9 fat-liquefied wounds and 2 infectious wounds, respectively. The wound-healing rate of patients with hydrocolloid was 87.5% (23 out of 24), a figure much higher than the controlled subjects (P = 0.049). Only 13 of 21 abdominal incisions (61.9%) were healed through gauze compression. CONCLUSIONS: Considering the preventive application of hydrocolloid after radical cystectomy could reduce wound exudates, prevent fat liquefaction, reduce dressing changes, relieve pain, and lower the economical burden, this method could be considered to facilitate wound healing for patients after radical cystectomy.

Wound—Preventative Practices New



Julie Yerke, MSN, ACNP-BC, CWCN-AP, CFCN, , and Traci Tillery, MSN, FNP-BC, CWOCN-AP, CFCN, , Specialty Services, Rome, GA

INTRODUCTION: This Northwest Georgia community had a need for diabetic nail care that could not be provided during acute hospitalizations. The need identified the demand for an outpatient service for preventive foot care to be provided for a select population group. OBJECTIVE: It was hypothesized that the number of amputations would decrease among diabetic patients who routinely received preventive foot care, which includes screening, education, and interventions, at a Northwest Georgia nurse practitioner–driven foot clinic. METHODS: A randomized retrospective chart review was performed on 292 diabetic patients, who were provided preventive foot care with a mean duration of 29.31 months by nurse practitioners at a Northwest Georgia Foot Clinic. The average age was 69.26 with 55.8% being male and 22.6% being African American. In addition, 69.2% were diagnosed with loss of protective sensation (LOPS). Foot deformities noted included the following: 101 patients had hallux valgus, 164 had hammer toes, 13 had Charcot's deformity. Of the population, 44.9% wear therapeutic diabetic footwear. RESULTS: Prior to preventive foot care, 23 patients had amputations due to diabetic foot ulcers (DFUs). Collective data revealed no patients suffered an amputation during the treatment plan. This represents 0% of the treated diabetic patient sample with a standard deviation of 0.00. CONCLUSION: The data reveals a statistical significance in this nurse practitioner–driven clinic. Preventive foot care is having an impact in reducing amputations in this Northwest Georgia community. Furthermore, this also represents a projected 2.1 million dollar cost avoidance for this Northwest Georgia Community Hospital.

Agency for Healthcare Research and Quality. Healthcare cost and utilization project highlights. on August 21, 2014. Published 2005.

Alper Atr A, Polt A, Tanrwerdi F, Ali A. Malignant melanoma misdiagnosed as a diabetic foot ulcer. WOUNDS A Compendium Clin Res Pract. 2012;24(2):43–46.

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Professional Practice—Satisfaction Measurement



Joan Sacerio, MHSA, BSN, RN-BC, CHPN, , Professional Practice Department, Jacksonville, FL, and Donna Geiger, BSN, RN, CWON, , Wound Care and Ostomy Services Department, Jacksonville, FL

In 2012, an analysis by the Patient Safety Committee of hospital-acquired events, insurance carrier actuarial data, and Patient Safety Organization benchmarking studies revealed an increase in number and severity of pressure ulcers (PUs), inconsistent staging, documentation, and poor skin assessment in 1 critical care areas. The primary aim of this research study was to evaluate the impact providing nurses advanced training on the prevention of PUs would have on early recognition and treatment of pressure ulcers. Another aim of the study was to evaluate whether daily skin assessments performed by specially trained nurses would result in a decreased occurrence of avoidable PUs. Eight critical care nurses received training by attending the Wound Treatment Associate program (WTA) for 3 months. The program is endorsed by the Wound Ostomy Continence Nurses Society. The WTA program enabled nurses to assist with daily patient monitoring, pressure ulcer prevention, and basic wound management under the direction of a certified wound care nurse. The WTAs performed skin assessments every 24 hours for 3 months on all eligible patients in the 2 critical care units. The WTAs identified skin breakdown and noted these findings on a bedside tracking tool, indicating the stage of the pressure ulcer, in which a consult was placed to the wound care team. At the conclusion of the research project, daily skin assessments resulted in early recognition, documentation, and treatment of skin breakdown. This, in turn, led to the resolution of suspected deep tissue injury and stage 1 ulcers preventing advancement to a higher stage and developing an early treatment plan for those pressure ulcers stage 2 or higher, which also resulted in increased healing. PUs identified during the research project led to resolution of suspected deep tissue injuries, stage 1—32% healed, stage 2—33% healed, stage 3—11% healed, suspected deep tissue injury—21% healed, unstageable—18% healed, moisture lesions—15% healed.

Estilo M, Angeles P, Hernandez V. Pressure ulcers in the intensive care unit: new perspectives on an old problem. Crit Care Nurse. 2012;32(3):65–70. doi:10.4037/ccn2012637.

House S, Giles T, Whitcomb J. Benchmarking to the international pressure ulcer prevalence survey. J Wound Ostomy Continence Nurs. 2011;38(3):254–259. doi:10.1097/won.0b013e318215fa48.

Never Events. Patient Safety Primer. Agency for Healthcare Research and Quality; 2012. Accessed October 15, 2014.

Van Gilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 international pressure ulcer prevalence survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage. 2009;55(11).

WOCN Society's Wound Treatment Associate (WTA) Program. Wound, Ostomy and Continence Nurses Society. Accessed October 17, 2014.

Author Index to Abstracts

© 2016 by the Wound, Ostomy and Continence Nurses Society.