Scientific and Clinical Abstracts From the WOCN® Society's 49th Annual Conference: Salt Lake City, Utah May 19-23, 2017 : Journal of Wound Ostomy & Continence Nursing

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Scientific and Clinical Abstracts From the WOCN® Society's 49th Annual Conference

Salt Lake City, Utah May 19-23, 2017

Journal of Wound, Ostomy and Continence Nursing 44():p S1-S72, May/June 2017. | DOI: 10.1097/WON.0000000000000331
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(GS3) Rooted in Results: Research AbstractsSaturday, May 20, 2017—1:35 PM-2:35 PMResearch Abstract Continence—Evidence-Based Treatment and Management



Julie Starr, APRN, FNP, , Lisa Brennaman, MD, , and Raymond Foster, MD, , Center for Female Continence and Advanced Pelvic Surgery, Columbia, MO; and Drobnis Erma, PhD, , OB/GYN Associates, Columbia, MO

OBJECTIVE: Women with symptoms of pelvic floor dysfunction (PFD) often consult with many different health care providers, increasing the potential for duplication and treatment delay. Multiple referrals can result in increased cost of care and decreased patient satisfaction. Nurse practitioners (NPs) in a female continence center are uniquely positioned to provide comprehensive, nonsurgical care for women with urinary, defecatory, and pelvic pain complaints. The aim of this study was to determine immediate- and long-term effectiveness of comprehensive pelvic floor rehabilitative administered by an NP. METHODS: This study is a single-arm, prospective clinic≠al trial. All adult women presenting to an academic urogynecology clinic seeking nonsurgical management for symptoms of PFD from February 1, 2013, to March 31, 2016, were offered enrollment. Subjects completed up to 5 treatment sessions with an NP that included pelvic muscle biofeedback, vaginal electrogalvanic stimulation, behavior modification, bowel symptom management, home pelvic floor exercise program, and (when appropriate) pessary fitting and pharmacologic intervention. Data were collected at baseline, end of treatment, and at 6 and 12 months following completion: validated quality-of-life (QOL) instruments (PFDI-20 and PFIQ-7) and patient global impression of improvement (PGI-I) measured by the visual analog scale. RESULTS: To date, 428 women have been enrolled, with 406 having complete data sufficient for analysis. These subjects had a median age of 51 years and parity of 2. Forty-eight percent reported a history of third- or fourth-degree obstetrical injury. Subjects experienced clinical and statistically significant improvement in QOL (P = .0005), which was durable at 1 year. PGI-I data revealed an 80% improvement in urinary, defecatory, and pain symptoms. Significant improvement in symptoms of nocturia (P = .01) and urinary frequency (P = .009) was also detected. CONCLUSION: Comprehensive nonsurgical management of women with symptoms of PFD by an NP is efficacious and results in improved QOL, which is durable up to 1 year.

Butrick CW. Pelvic floor hypertonic disorders: identification and management. Obstet Gynecol Clin N Am. 2009;36(3):707–722. doi:10.1016/j.ogc.2009.08.011.

Herderschee R, Hay-Smith EJ, Herbison GP, Roovers JP, Heineman MJ. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011;(7):CD009252. doi:10.1002/14651858.CD009252.

Norton C, Cody JD. Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev. 2012;7:CD002111. doi:10.1002/14651858.CD002111.pub3.

Rai BP, Cody JD, Alhasso A, Stewart L. Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2012;12:CD003193. doi:10.1002/14651858.CD003193.pub4.

Starr JA, Drobnis EZ, Lenger S, Parrot J, Barrier B, Foster R. Outcomes of a comprehensive nonsurgical approach to pelvic floor rehabilitation for urinary symptoms, defecatory dysfunction, and pelvic pain. Female Pelvic Med Reconstr Surg. 2013;19(5):260–265. doi:10.1097/SPV.0b013e31829cbb9b.

Wound—Management of Complex Wounds



Joy Pittman, PhD, ANP-BC, FNP-BC, CWOCN, , Wound Ostomy Continence, Indianapolis, IN; Terrie Beeson, MSN, RN, CCRN, ACNS-BC, , and Jill Dillon, MSN, RN, CCRN, ACNS-BC, , Indiana University Health, Indianapolis, IN; and Janet Cuddigan, PhD, RN, CWCN, FAAN, , School of Nursing, Omaha, NE

Healthcare organizations strive to minimize harm and provide a safe environment. Despite technological advancements, hospital-acquired pressure injuries (HAPIs) continue to occur. This raises the question if HAPIs may be unavoidable. The purpose of this study was to (1) identify the proportion of HAPIs among patients in intensive care unit (ICU)/PCU that are unavoidable and (2) identify risk factors among patients that differentiate avoidable from unavoidable HAPIs. This descriptive, retrospective study examined 165 adult patients who developed an HAPI while hospitalized in ICU/PCU during 2013-2015. Using the Pressure Ulcer Prevention Inventory (a validated tool measuring implementation of risk-based interventions based on Braden subscale scores), more than 41% (67) of the HAPIs were identified as unavoidable. The majority of HAPIs were deep tissue injuries (N = 102, 62%), stage 2 (N = 34, 21%), and unstageable (N = 25, 15%). More than 36% (60) of HAPIs were device related. Of the 47 risk factors examined, having a bowel management system was positively associated with an unavoidable HAPI (P = .04). Length of stay (LOS) in the unavoidable group was higher (18 vs 13 days) (P = .057) and having a previous pressure injury approached statistical significance (P = .09). Using logistic regression, only LOS was statistically significant. For each 1-day increase in LOS, the odds of developing an unavoidable HAPI increased by 3.6% (P = .02). The number of HAPI prevention interventions in each group was statistically different, with unavoidable group having more interventions implemented for the Braden subscales of Mobility (P ≤ .0001), Activity (P ≤ .0001), Sensory Perception (P = .0002), Nutrition (P ≤ .0001), and Friction/Shear (P = .001). The primary difference between patients with avoidable versus unavoidable HAPIs was not the participants' risk factors but rather the prevention interventions provided. Interventions for mobility and nutrition were consistently lacking in the avoidable group.

Ayello E, Lyder C. Protecting patients from harm: preventing pressure ulcers. Nursing. 2007;47(10):40–41.

Centers for Medicare & Medicaid Services. State Operations Manual. Guidance to Surveyors for Long-term Care Facilities. Transmittal 4. CMS Manual System. Washington, DC: Department of Health and Human Services; 2004. DHHS Pub No. 100-07.

Centers for Medicare & Medicaid Services. Certification Regulations and Guidance for Certified Nursing Facilities (F314) 42 CFR 483.25(c), Pressure Sores 193-228.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

National Pressure Ulcer Advisory Panel. Not All Pressure Ulcers Are Avoidable. Washington, DC: National Pressure Ulcer Advisory Panel; 2010.

Pittman J, Beeson T, Dillon J, et al Unavoidable pressure ulcers: development and testing of the Indiana University Health Pressure Ulcer Prevention Inventory. J Wound Ostomy Continence Nurs. 2016;43(1):32–38.

Sacks D. Content Validity Study for a Survey to Measure Faculty Attitudes Towards Research and Teaching at a Doctoral/Research Extensive University. Cincinnati, OH: College of Education, Criminal Justice, and Human Services, University of Cincinnati.

Thomas D. Are all pressure ulcers avoidable? J Am Med Dir Assoc. 2003;4(2)(suppl):S43–S48.

WOCN Society. Wound, Ostomy and Continence Nurses Society position statement on avoidable versus unavoidable pressure ulcers. J Wound Ostomy Continence Nurs. 2009;36(4):378–381.

Ostomy—Evidence-Based Interventions



Jeffrey Doucette, MSN, RN, CWOCN, , Nursing Education, Westwood, MA

BACKGROUND AND PURPOSE: Persons with new ostomies are a vulnerable population who require complex care management. In addition to having to learn stoma management during their convalescent period, they often experience significant and frequent impairment of their psychosocial well-being, which can affect adjustment to the stoma and hamper efforts to learn self-care. As nurses employ various interventions to assist the patient and the caregiver to overcome challenges, a wide range of patient outcomes are reported, indicating a need for comprehensive tools to help manage these patients. PURPOSE: The aim of this study was to evaluate new ostomy patients' psychosocial adjustment after receiving instruction with an ostomy care pathway. METHOD: A quasi-experimental research design was utilized to evaluate outcomes of a convenience sample of adults (n = 49) with a new fecal or urinary diversion, who were discharged home from an acute or skilled nursing facility. An ostomy care pathway applying evidence-based practices was developed and implemented to support patient recovery by nurses from one office at a home care agency; nurses at another office delivered traditional teaching based on professional experience. The Ostomy Adjustment Inventory 23 (OAI-23), a 23-item self-report survey designed to measure ostomy adjustment in adult persons with an intestinal ostomy, was administered to every participant once self-care was achieved. RESULTS: A Mann-Whitney U test was used to compare mean rank scores across the experimental and control groups. Participants who were taught ostomy care using the ostomy care pathway ranked higher in adjustment scores (P < .001). In addition, married participants scored significantly higher in adjustment than single participants (P = .033). CONCLUSION: Utilization of an evidence-based ostomy care pathway assisted patients to achieve higher adjustment scores, and married persons attained higher adjustment scores than single persons.

Cross HH, Roe CA, Wang D. 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. doi:10.1097/WON.0000000000000065.

Lim SH, Wai CC, He H. Patients' experiences of performing self-care of stomas in the initial postoperative period. Cancer Nurs. 2015;38(3):185–193. doi:10.1097/NCC.0000000000000158.

Mota MS, Gomes GC, Petuco VM, Heck RM, Barros EJ, Gomes VL. Facilitators of the transition process for the self-care of the person with stoma: subsidies for nursing. J School Nurs. 2015;49(1):80–86. doi:10.1590/S0080-623420150000100011.

Simmons KL, Smith JA, Maekawa A. Development and psychometric evaluation of the Ostomy Adjustment Inventory-23. J Wound Ostomy Continence Nurs. 2009;36(1):69–76. doi:10.1097/WON.0b013e3181919b7d.

Wound—Preventative Practices New



Judith J. Stellar, MSN, CRNP, PPCNP-BC, CWOCN, , Darcy L. Brodecki, BS, , and Larissa Hutchins, MSN, RN, CCRN, CCNS, , Nursing, Philadelphia, PA; and Katherine Finn Davis, PhD, APRN, CPNP, , School of Nursing and Dental Hygiene, Honolulu, HI

BACKGROUND: Hospital-acquired pressure injury (HAPI) is a serious, often preventable problem, increasing costs, length of stay, and patient suffering. Although well documented in adults, there is little evidence regarding the pediatric population. Our institution recognized areas for improvement. We set out to describe HAPI in infants and children and, based on the pattern and characteristics of these injuries, develop specific, targeted interventions to improve patient outcomes, including a wide array of medical device-related HAPIs (MDRHAPIs). METHOD: An institutional review board–approved study consisting of a series of prevalence surveys was conducted. A Web-based tool, Research Electronic Data Capture (REDCap1), was used to document presence, severity, and etiology of HAPI and review accuracy of clinical documentation. The research study evolved into quality improvement, and REDCap allowed for survey customization where medical devices, locations, and anesthetized procedures were assessed and trended over a 6-year period. Summary statistics were used to determine prevalence for each HAPI category. RESULTS: Over 25 quarterly surveys, a total of 10,892 patients were assessed, with an average of 435 patients per survey. Prevalence ranged from 4.93% early on to 0.7%, with a median of 1.63%. MDRHAPIs accounted for 70% to 100% of the injuries. Respiratory devices were the most frequent cause of MDRHAPIs, followed by vascular devices and orthotics. Injury location corresponded to etiology; MDRHAPIs were located around the face, neck, and extremities, whereas immobility HAPIs were most often located to the occiput and sacrum. Trending of HAPIs over time will be presented along with specific practice changes and interventions. IMPLICATIONS: These data confirm that MDRHAPI is a leading cause of HAPI in pediatrics. A customizable tool such as REDCap assists in “drilling down” to the root cause of each HAPI, allowing for targeted interventions. Ongoing prevalence surveys continue to monitor care and patient outcomes, striving for sustainability of improvements.

1. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.

(W300) Wound Abstract PresentationsSunday, May 21, 2017—8:40 AM–9:40 AMWound—Management of Complex Wounds



Chun-Lin Su, , Taoyuan, China; Yun-Shing Peng, , and Mei-Yen Chen, , Chiayi, China; and Chang-Cheng Chang, , Taichung, China

OBJECTIVE: This study aimed to investigate the predictive factors focused on treatment response of King's classification III diabetic foot ulcer (DFU). METHOD: This prospective study included 100 patients with King's classification III DFU treated in outpatient clinics in Chiayi Chang Gung Memorial Hospital from January 2011 to December 2011. The least follow-up time was 1 year. Medical documentations were in respect of patients' profiles, previous associated histories, and presence of comorbidities, follow-up time, and condition of wounds. Fisher's exact test and one-way analysis of variance were used for variables in the 3 groups: treatment success (healed or healing with wound reduction), stagnate, and failure (amputation or infection needs in-hospital medical service) groups, while the t test was applied for those in 2 groups: comparison, failure versus nonfailure and success versus nonsuccess groups. RESULT: With 3 groups, stratification was according to treatment response: failure (n = 8), stagnate (n = 22), and success (n = 70); rates of occurrence of retinopathy were higher in the treatment stagnate group (42.1%) than in the treatment failure (14.3%) and success groups (12.5%) (P = .019); rates of previous PTA were higher in the treatment failure group (25%) than in the treatment stagnate (4.8%) and success groups (1.5%) (P = .020). With 2 groups, stratification was failure (n = 8) versus nonfailure (n = 92), and success (n = 70) versus nonsuccess (n = 30); previous PTA history was strongly associated with treatment failure (odds ratio [OR] = 14.33; 95% confidence interval [CI], 1.71-120.32; P = .014); retinopathy (OR = 0.21; 95% CI, 0.07-0.65; P = .007) was the major negative predictor for treatment success. Gender, age, previous associated histories, coronary artery disease, cerebrovascular accident, end-stage renal disease, and wound conditions had no statistically significant difference. CONCLUSION: Previous PTA and retinopathy are major predictive factors for treatment failure or nonsuccess, concluding that the unhealed DFU in outpatient clinics was mainly precipitated by preexisting peripheral vascular problems.

1. Fard AS, Esmaelzadeh M, Larijani B. Assessment and treatment of diabetic foot ulcer. Int J Clin Pract. 2007;61(11):1931–1938.

2. Edmonds ME, Foster AV. Managing the Diabetic Foot. Chichester, West Sussex, England: John Wiley & Sons; 2013.

3. Nather A, Bee CS, Huak CY, et al Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22(2):77–82.

4. Tsai FC, Lan YC, Muo CH, et al Subsequent ischemic events associated with lower extremity amputations in patients with type 2 diabetes: a population-based cohort study. Diabetes Res Clin Pract. 2015;107(1):85–93.

5. Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev. 2000;16(S1):S75–S83.

Wound—Preventative Practices New



Cheryl Postlewaite, MSN, RN, CWCN, , Nursing Education, Practice, and Research, Asheville, NC; Vallire Hooper, PhD, RN, CPAN, FAAN, , Nursing Practice, Education, and Research, Asheville, NC; Jeanie Bollinger, MSN, RN, ACCNS-AG, , Nursing, Asheville, NC; and Sheri Denslow, PhD, MPH, , Research Institute Administration, Asheville, NC

INTRODUCTION: Hospital-acquired pressure ulcers continue to pose a significant health problem in the United States, affecting up to 3 million adults in acute care facilities at a cost of up to $11 billion annually. Surgical patients are at elevated risk for pressure ulcer development due to a combination of physiological, nonphysiological, and surgical/anesthesia-related factors. IDENTIFICATION OF THE PROBLEM: The Braden Scale score (BrS) is well accepted as a predictor of pressure ulcer risk; however, the preoperative BrS may not accurately reflect postoperative risk. The Scott Triggers (ST) scale shows great potential as a preoperative predictor of postoperative pressure ulcer (PPU) risk but has not been tested for predictive capacity. METHODOLOGY: A retrospective, exploratory research design using electronic medical record abstraction was used. A purposive convenience sample of medical records of all adult patients (>18 years of age) undergoing any inpatient surgical procedure over a 1-year period was included. RESULTS: Data from 15,500 charts were abstracted. ST and first postoperative BrS were significantly correlated (r =−0.48, P < .01). Three of the 4 ST factors (age, ASA score, surgery duration) were predictive of a change in BrS from preoperative to postoperative assessment (P < .01 for each). Preoperative albumin level was not evaluated due to a lack of data. Results also showed increased pressure ulcer risk (P < .01) with any surgery. CONCLUSION: Three of the ST triggers are predictive of PPU risk. IMPLICATIONS FOR FUTURE RESEARCH: Further research as to the interaction of other perioperative factors to PPU risk is indicated. Implementation of a simple, preoperative PPU risk assessment tool with strong predictive metrics will enable perianesthesia nurses to work proactively in implementing preventative interventions to reduce PPU risk in the surgical population. Such interventions should contribute to reduced healthcare costs and significantly improved patient outcomes.

American Academy of Nursing. Perioperative pressure ulcer prevention program. Raise the Voice: Edge Runner. http:// Published 2012. Accessed October 31, 2012.

Bergstrom N, Braden BJ, Laguazza A, Holmon V. The Braden Scale for predicting pressure sore risk: reliability studies. Nurs Res. 1987;36:205–210.

Carstens J. Pressure ulcers: prevention and management. Joanna Briggs Institute Web site. Published 2011.

Esch D. Scott Triggers: a screening tool for pressure ulcer prevention in surgical patients. J Perianesth Nurs. 2010;25(3):186.

He W. The Braden Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: a meta-analysis. Ostomy Wound Manage. 2012;58(2):34–40.

Wound—Dermatological Management/Issues



Donna Z. Bliss, PhD, RN, FAAN, FGSA, , Olga V. Gurvich, MA, , Kay Savik, MS, , Susan Harms, PhD, RPh, , Christine Mueller, PhD, RN, FAAN, FGSA, , and Kjerstie R. Wiltzen, BA, BSN, RN, , School of Nursing, Minneapolis, MN; and Lynn E. Eberly, PhD, , and Kristen Cunanan, PhD, , Biostatistics Division, School of Public Health, Minneapolis, MN

BACKGROUND: There are racial/ethnic disparities in the prevalence and incidence of pressure injury (PrI) in nursing home (NH) residents, but little is known about disparities in PrI healing. PURPOSE: To assess racial/ethnic disparities in the healing of PrI present at NH admission. METHODS: Data sets: Minimum Data Set (MDS) (residents' characteristics, PrI presence/stage) and Online Survey, Certification, and Reporting (NH characteristics/staffing/care deficiencies) from 2000 to 2002, and 2000 US Census (socioeconomic status of communities around NHs). In a cohort design, MDS records of NH admissions 65+ years with any stage 2-4 PrI (n = 10,862) were searched to the 90-day assessment + 2 weeks for the first record without any PrI reported, defining PrI healing. Disparity was assessed with the Peters-Belson method. Potential predictors of PrI healing were first modeled for whites using logistic regression. Coefficients from the white model were applied to each minority group in separate models, enabling estimation of the percentage of minorities expected to heal PrI, had they been in the white group, which were then compared to the percentage observed to heal PrI using z-tests. RESULTS: Admissions with PrI (63% female, aged 82 [7.8]) years (mean [SD]), 80% white, 15% black, 2% Asian, 2% Hispanic) were in 439 NHs in 27 states. PrI healed in 44% of residents overall. Disparity was found for blacks: a significantly smaller percentage of black admissions (37%) had PrI healed than expected had they been part of the white group (40%). Odds of PrI healing were significantly lower if PrI was more severe, that is, stage 3 (OR [95% CI]) (0.3 [0.25-0.36] or stage 4 (0.3 [0.25-0.36]) versus stage 2, or if the NH admission had greater deficits in activities of daily living (0.97 [0.96-0.99]). CONCLUSIONS: Knowledge of disparities in PrI healing can direct interventions to ensure equity in NH care, which WOC nurses can facilitate and provide leadership.

Wound—Preventative Practices New



Martha Taylor, BSN, RN, CWON, , Professional Practice, Ft Lauderdale, FL; Harvey Mayrovitz, PhD, , Health Professions Division, College of Medical Sciences, Ft Lauderdale, FL; and Paige Spagna, OMS-1, , College of Medical Sciences, Fort Lauderdale, FL

PURPOSE: Hospital-acquired pressure ulcers (HAPUs) result in about 2.5 million patients in acute care hospitals treated for HAPUs annually. Although it is assumed that patients with vascular deficits entering an intensive care unit (ICU) are at increased risk for HAPUs, there is no validated quantitative method in which ICU patients can be rapidly and efficiently screened to determine who are more likely to develop an HAPU. Our specific aim was to determine the utility of a new commercial infrared thermal imaging system to discriminate at-risk levels of ICU patients from skin temperature differences between pressure ulcer–prone sites (sacrum) and remote not-at-risk control skin sites. METHODS: Buttocks and lower back areas of 100 ICU patients were photographed to obtain simultaneous infrared thermal and standard images. Images were analyzed by comparing temperature differentials between the sacrum and a distant control skin site within the image. A decreased perfusion leading to an increased breakdown risk threshold (RISK-T) was defined if sacral temperature was 1.5°C less than the control site. This threshold was based on prior data for sacrum showing it to normally be 0.75°C less the lower back. The underlying hypothesis was that patients with vascular disease would be more likely to exceed RISK-T than patients not so diagnosed. RESULTS: Of 100 patients imaged, 68 had vascular disease (VASD) consisting of peripheral (PAD) and/or coronary (CAD). Of these, 14/68 (20.6%) exceeded ART whereas for patients without diagnosed VASD (NO-VASD), 6/32 (18.8%) exceeded ART. Chi-square analysis of these proportions shows no significant difference between VASD and NO-VASD patients with respect to exceeding the thermal differential threshold. CONCLUSIONS: Although infrared thermal screening may provide visually impressive and potentially useful images in some cases, the use of temperature differentials to detect patients at particularly high risk related to vascular status is not supported by the present results.

(C502) Continence Abstract PresentationsTuesday, May 23, 2017—8:00 AM-9:00 AMContinence—Evidence-Based Treatment and Management



Ying Sheng, MSN, RN, , School of Nursing, Ann Arbor, MI; and Janis Miller, PhD, RN, APRN, FAAN, , Ann Arbor, MI

BACKGROUND: First-line stress urinary incontinence (SUI) treatment in postpartum is pelvic floor muscle training (PFMT), typically involving minimally 30 contractions (Exercise method) along with instruction in contracting with intra-abdominal pressure rise, such as cough or sneeze (Knack method). PFMT effect on leakage is thought to be due to exercise-related pelvic muscle strength gain. Reports of statistical correlation of relationship between strength change and incontinence change are lacking. Long-term adherence to the Exercise method is challenging. The Knack method has shown immediate effect in clinic environment on the standing stress test without time for strength change. The long-term goal of our work is to find the most parsimonious but effective form of PFMT for busy postpartum women with SUI. To begin, we aim to determine if pelvic muscle strength change correlates with SUI symptom change in postpartum women assigned to both the Exercise method and the Knack method. METHODS: Design: A cohort longitudinal study with women evaluated at 6 weeks and 7 months postpartum for levator ani strength and for urinary incontinence (Sandvik score, Antonakos score). In total, 151 postpartum women, all taught pelvic muscle training method (Exercise and Knack) with hands on instruction during a pelvic exam and visual feedback of contraction by ultrasound. Data were analyzed by Spearman's correlation for strength of association between strength change and incontinence reduction for women who had complete data at both time points. RESULTS: Correlations coefficients were weak and nonsignificant between the change of pelvic muscle strength and the change in incontinence measures: Sandvik (r =−0.061, P = .66, n = 56), Antonakos (r = 0.140, P = .25, n = 69) questionnaires. CONCLUSION: In postpartum women, pelvic muscle strength change does not explain change in incontinence over the postpartum year. Further research is advised to explore the role of skill acquisition through the Knack method, the role of natural history of recovery, and other potential explanation for improvement of SUI symptoms.

Wound—Dermatological Management/Issues



Kathleen Francis, MSN, CWOCN, FNP-BC, , Nursing, Brooklyn, NY

CLINICAL PROBLEM: Accurate classification of skin injuries and identification of their etiology are paramount to ensuring that the correct treatment plan is initiated to halt the injury and positively affect healing. The average clinician has difficulty in making the correct identification owing to the fact that these injuries have very subtle differences. This is particularly true in patients with dark skin tones, as visual cues associated with these types of skin injuries may not be sufficient. INTERVENTION: The project included the development and implementation of education sessions for the staff working at a skilled nursing facility. The education sessions were voluntary, and consent was presumed with their attendance and with their completion of the pre- and posttests. COMPARISON: A pre/posttest design was utilized for this project. The items were content validated by review of 4 WOC nurses and colleagues who agreed to review it. The pre/posttests also included 2 Likert-type items to measure attitude regarding the subjects' ability to differentiate skin injuries. OUTCOME: A total of 37 subjects attended the sessions. Three subjects declined to complete either the pretest or the posttest, or both, and were excluded from the study. Posttest scores were increased by approximately 20%. Statistical analysis was completed using a paired t test. The increase in posttest scores was found to be statistically significant (P = .000). Internal consistency was measured with the Cronbach α; tests were reliable with a Cronbach α of 0.95. CONCLUSION: Appropriate treatment of skin injury can only occur when the etiology is correctly identified. Clinicians often have difficulty identifying early signs of skin injury in patients with dark skin tones. Tools that can be readily available and easily utilized by the clinician at the bedside are needed.

Ayello EA, Sibbald RG, Quiambo PC, Razor B. Introducing a moisture-associated skin assessment photo guide for brown pigmented skin. WCET J. 2014;34(2):18–25.

Doughty DB, McNichol LL. General concepts related to skin and soft tissue injury caused by mechanical factors. In: Doughty D, McNichol L, eds. Wound Ostomy Continence Nurse Society Core Curriculum: Wound Management. 1st ed. 2016:273–279.

Mahoney M, Rosenbloom B, Doughty D, Smith H. Issues related to accurate classification of buttock wounds. J Wound Ostomy Continence Nurs. 2011;38(6):635–642.

Metersky ML, Hunt DR, Kliman R, et al Racial disparities in the frequency of patient safety events: results from the national Medicare patient safety monitoring system. Med Care. 2011;49(5):504–510.

The National Pressure Ulcer Advisory Panel. The National Pressure Ulcer Advisory Panel announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. http:// Published April 13, 2016. Accessed May 1, 2016.

Continence—Evidence-Based Treatment and Management



Donna Z. Bliss, PhD, RN, FAAN, FGSA, , Olga V. Gurvich, MA, , 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, , Biostatistics Division, School of Public Health, Minneapolis, MN; and Beth Virnig, PhD, , School of Public Health, Minneapolis, MN

PURPOSE: Reports of racial/ethnic disparities in nursing home (NH) care prompted this investigation of disparities in managing incontinence that developed after NH admission. METHODS: Data sets: Minimum Data Set (residents' characteristics, incontinence, incontinence management) and Online Survey, Certification, and Reporting (NH characteristics/staffing/care deficiencies) from 2000 to 2002 and 2000 US Census (socioeconomic status of communities around NHs). In a cohort design, 2 outcomes of incontinent residents aged 65+ years (n = 8638 in 447 NHs in 28 states) were analyzed: (1) any incontinence management versus no management; (2) conservative + behavioral management versus conservative management alone. Disparity was assessed with the Peters-Belson method: Predictors of incontinence management were modeled for whites using logistic regression. Resulting coefficients were applied to minority groups in separate models estimating the % minorities expected to receive management, had they been in the white group. These percentages were then compared to the percentages observed to receive management using z-tests. RESULTS: Incontinent residents were 71% female, aged (83 [8]) years (mean [SD]), 89% white, 8% black, 1% Hispanic, and 1% Asian. Of the 7961 residents with incontinence management data, 77% received any management; 41% of those received conservative + behavioral management. The % disparity was significant for blacks (7.5%, P = .001) and Hispanics (8.6%, P = .006) for any management and for blacks for behavioral + conservative management (P = .01). Significant predictors (odds ratio [95% confidence interval]) of receiving any incontinence management in the white model applied to blacks were greater activities of daily living (ADL) limitations (1.02 [1.01-1.03]), high school education (1.23 [1.02-1.47]), fewer cognitive deficits (0.92 [0.86-0.99]), and fewer quality care deficiencies (0.97 [0.96-0.99]). Predictors of any management in the white model applied to Hispanics were greater ADL limitations (1.05 [1.02-1.08]) and fewer cognitive deficits (0.94 [0.92-0.97]). Predictors of behavioral + conservative management in the white model applied to blacks were lesser ADL limitations (0.97 [0.96-0.98]) and greater cognitive deficits (1.22 [1.13-1.32]). CONCLUSION: Achieving equity in incontinence management in NHs is needed, and WOC nurses can assist.

(O505) Ostomy Abstract PresentationsTuesday, May 23, 2017—10:20 AM-11:20 AM

Ostomy—Psychosocial and Quality-of-Life Aspects



Jane Ellen Barr, DNP, RN, CWON, , Nursing Administration, Seaford, NY

Persons who have ostomy surgery live with ongoing physical and psychological losses. The purpose of this study was to explore the relationship of resilience to chronic sorrow in persons living with an ostomy. A descriptive, correlational design was used with a convenience sample of 254 persons living with an ostomy. Study participants completed a questionnaire that included 3 sections: demographics and background information, Kendall Chronic Sorrow Instrument, and Connor-Davidson Resilience Scale (CD-RISC). Descriptive and correlational analyses were used to examine the relationship between and among the variables. Results showed that the correlation between resilience and chronic sorrow was r =−0.5 and was statistically significant at P < .001. Strong statistically significant relationships (P < .5) were found between participants having chronic sorrow and less resilience in age groups 18 to 45 years, persons living with an ostomy 2 months to 6 years, those ostomates who had a permanent colostomy, and those who felt they were not given adequate education to manage their ostomy at the time of surgery. Among the participants, 75 (30%) ostomates experienced chronic sorrow as an adaptation process to living with a stoma. Since resilience can be fostered in individuals who experience an adverse event such as an ostomy, nursing can draw on the interventional strategy of developing resilience to support ostomy patients' adaptation to living with their ongoing losses.

Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson resilience scale (CD-RISC). Depress Anxiety. 2003;18(2):76–82. doi:10.1002/da.10113.

Kendall L. The experience of living ongoing loss: testing the Kendall Chronic Sorrow Instrument. Dissertation Abstr Int Sect B Sci Eng. 2006;66(5902):11B.

Cheng F, Meng A, Yang L, Zhang Y. The correlation between ostomy knowledge and self-care ability with psychosocial adjustment in Chinese patients with a permanent colostomy: a descriptive study. Ostomy Wound Manage. 2013;59(7):35–38.



Anita C. Prinz, MSN, RN, CWOCN, , Wound & Ostomy, Wellington, FL; and Joy Hooper, BSN, RN, CWOCN, , Plainfield, IL

Social media is changing the way people communicate. As of June 2016, Facebook (FB) had 1.71 billion monthly users.1 As the general public embraces social media, the healthcare community must as well. Ostomy patients are increasingly using social media as part of their disease management. Ostomy clinicians have an obligation to be current on all community resources available to the public. The purpose of this descriptive study was to discover who the users are in FB ostomy groups and common themes. Subsequently, ostomy clinicians can learn what the current needs are of the ostomy community and take this information back to improve practice. Data were collected by observation of members' posts and sorted into 17 topics. A search using the key word “ostomy” was performed in the FB search bar. The search was narrowed to the 7 largest ostomy groups comprising 48,238 members. Observation of all threads for 1 month was conducted. A quantitative, descriptive research study was conducted using the 7 largest FB ostomy groups. Statistical analysis was limited to descriptive statistics to demonstrate age frequency distribution and identification of themes. Fifty ostomy groups were discovered on FB, with 26 closed (private) groups totaling 48,238 members. The age demographic of 147 users showed 16% aged 15 to 35 years, 62% were 36 to 55 years old, and 22% were 56 years and older. Nine themes emerged from 227 discussion threads: activities of daily living, emotions, output, comedy, peristomal skin problems, food, illness, supplies, and surgical issues. Expressing feeling was the most prevalent topic, followed by peristomal skin problems. Members of social media demonstrate empathy, compassion, and courage in sharing their experiences and knowledge. FB superusers have organized meetings, fund-raisers, and lobbying events, built ostomy pantries, and provided supply exchanges. Ostomy clinicians need be aware of how social media can be used to improve patient care.

1. Statista Inc. Number of monthly active Facebook users worldwide as of 2nd quarter 2016 (in millions).


CASE STUDY ABSTRACTSWound—Evidence-Based Interventions



Amy Gorecki, RN, CWOCN, , and Kimberly Schuster, RN, CWOCN, , St Cloud, MN; Patricia Dumonceaux, MSN, RN, CIC, PHN, , Lead Infection Prevention and Control, St Cloud, MN; and Melissa Erickson, MSN Ed, BSN, RNC-MNN, PHN, , Family Birthing Center, St Cloud, MN

PURPOSE: To reduce surgical site infections (SSIs) in women requiring a cesarean section at a Catholic regional level II trauma center in the Midwest. STRATEGY AND IMPLEMENTATION: An evidence-based practice and product approach was taken to reduce cesarean section SSIs. Postoperative wound care was standardized by developing high-risk criteria for the use of foam boarder dressing versus foam AG boarder dressings. It was soon identified upon review and outcomes that the foam AG dressing was the dressing of choice and added as the standard dressing. The practice of using preoperative chlorhexidine (CHG) wipes either at home or upon arrival to the hospital was changed to CHG showers, and a CHG preoperative scrub was added as part of the operative prep process. Iodine-infused incise drape and closing trays were implemented. EVALUATION: A more than 50% reduction in cesarean SSIs occurred after standardized incision and dressing practices. In 2015, there was a spike in SSIs when the CHG scrub was added as part of the operating room (OR) prep. It was determined the fenestrated drape was not adhering. Rapid replacement of drape type occurred, and closing trays were implemented. SSI rates have remained at 0.5% compared to NHSN mean of 1.8%. IMPLICATIONS FOR PRACTICE: Evidence and outcomes demonstrate that a standardized pre- and postoperative approach is required to prevent SSIs in women requiring a cesarean section. Prepping patients preoperatively with both CHG showers and scrubs is necessary along with contained OR traffic control. In addition, foam AG dressings were used on the surgical incision for 7 days. Collaboration amongst the multidisciplinary team is essential along with thorough case review of infections to identify gaps, opportunities, and actions needed to continue rates well below the benchmark.

Corcoran S, Jackson V, Coulter-Smith S, Loughrey J, McKenna P, Cafferkey M. Surgical site infection after cesarean section: implementing 3 changes to improve the quality of patient care. Am J Infect Control. 2013;41(12):1258–1263. doi:10.1016/j.ajic.2013.04.020.

Cutting K, White R, Hoekstra H. Topical silver-impregnated dressings and the importance of the dressing technology. Int Wound J. 2009;6(5):396–402. doi:10.1111/j.1742-481X.2009.00635.x.

Darouiche RO, Wall MJ Jr Itani KM, et al Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. New Engl J Med. 2010;362(1):18–26. doi:10.1056/NEJMoa0810988.

De Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387–397. doi:10.1016/j.ajic.2008.12.010.

Revolus T, Tetrokalashvilli M. Implementation of evidence-based innovative bundle checklist for reduction of surgical site infection. Obstet Gynecol. 2014;123:32S. doi:10.1097/01.AOG.00004 47301.55165.fe.

Wound—Product Selection and Innovations



Deanna Zaganas, BSN, RN, WOC, , and Dana Balassa, BSN, RN, WOC, , Glen Burnie, MD

FACILITY: An acute care hospital in the Northeastern United States. CLINICAL PROBLEM: Equipment was available at our facility, but it was not being utilized. We wanted to see if using the instillation* therapy would make a difference in our patient's wound healing. CLINICAL APPROACH: First, it was necessary to get the approval of a few surgeons who would allow us to use instillation* therapy on their patients. After the surgeons agreed on its use on their patients, the inpatient nursing staff had to be educated on how to monitor and/or troubleshoot the instillation* treatment process while they were taking care of a patient receiving this instillation* therapy. Three patients were selected for this case study, and serial pictures were taken at different intervals of their treatment. OUTCOME: The surgeons were happy with the appearance of their patients' wounds when the therapy dressings were changed. The instillation* therapy jump-started the healing process and therefore made the patients happier. The instillation and dwelling of approved fluids avoided the need for the patient to return to the operating room (OR) for washouts with dressing changes. CONCLUSION: Instillation* therapy was effective in jump-starting the wound-healing process and successfully promoted faster healing time while in an inpatient setting. It reduced the surgical risks to these patients by avoiding the need to return to the OR under anesthesia.

http:// Published 2014.

http:// Published 2014.

http:// Published 2016.

Kim P, Attinger C, Crist B. Negative pressure wound therapy with installation: review of evidence and recommendations. Wounds. 2015;27(12):1–20.

Kim P, Attinger C, Steinberg J, 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;133:709–716.

Wound—Management of Complex Wounds



Denise Manley, BSN, RN, COCN, CWCN, , and Nicole Harris, BN, RN, CWOCN, , Wound/Ostomy, Glendale, AZ

Negative pressure wound therapy with instillation (NPWTi) is typically used in cleansing the wound bed rather than moistening a graft. In the neonatal population, there is little evidence-based research on negative pressure wound therapy (NPWT) with the use of normal saline instillation. Traditional therapy included continuous NPWT to aid in bolstering the graft. “NPWT has revolutionized the management of open wounds by mechanisms of bacteria clearance, moisture elimination, edema reduction, and angiogenesis stimulation” (Evangelista, Kim, Evans, & Wirth, 2013, p. 1). Through innovative practice, 3 neonates were followed using case study approach to report how normal saline instillation can assist NPWT with bolstering and moistening the graft. Patient histories included gastroschisis, omphalocele, and pentalogy of Cantrell with omphalocele. All patients received therapy between 12 and 53 days. Instillation amount and length of time were titrated based on clinical findings with each dressing change. Of the 3 cases, 2 cases assisted with keeping the graft moist to allow it to regenerate with neonate's own tissue. There continues to be conflicting evidence regarding the benefits of NPWT with normal saline instillation. Each case provides a unique glimpse into the pros and cons of irrigation, which provides insight into future cases. More opportunities to do further case studies are much needed in order to see if normal saline instillation is an effective adjunctive therapy with NPWT.

Evangelista M, Kim E, Evans G, Wirth G. Management of skin grafts using negative pressure therapy: the effect of varied pressure on skin graft incorporation. Wounds. 2013;25(4):89–93. http://

Wound—Preventative Practices New



Shannon Glavaz, MSN, RN, CWOCN, , Wound Care, Pomona, CA, and Andrea Cordek, BSN, RN, CWOCN, , Wound Care, Pomona, CA

PURPOSE: Pressure injury (PI) prevention guidelines state that patients need to be repositioned so that pressure is redistributed.1 Studies show that health care providers (HCPs) are naive as to the actual pressure redistribution effects of their repositioning interventions due to turning blind. This allows patients continued exposure to high pressures,2 leading to PI development.

METHODS: Intensive care unit (ICU) patients are at higher risk for developing PIs.3 So, all ICU mattresses were equipped with real-time pressure monitoring (RTPM) systems for 3 months. An evaluation was done to measure the effectiveness in identifying patients' exposure to high pressure areas and to assess if interventions were able to lower high pressures to decrease PIs. The RTPM systems gave HCPs a visual image of pressures under patients and monitor those pressures continuously. HCPs used pressure images to effectively reposition patients, manage appropriate settings on beds, and utilize the alerts to turn patients by their individually determined turn schedules. RESULTS: HCPs found the RTPM systems easy to use. High pressures were decreased through interventions, and interventions were monitored to ensure patients were not exposed to high pressures throughout their stay. Peak pressures were recorded on 15 random patients. The HCPs repositioned patients, first, without looking at the image and then looking at the image to make additional small adjustments to the patients' positions using microshifting and adjusting air in the mattresses. Peak pressures ranged from 50 to 148 mm Hg, with an average of 78 mm Hg when the RTPM was not utilized for positioning. When the RTPM was utilized for positioning, peak pressures ranged from 27 to 49 mm Hg, with an average of 38 mm Hg. No new pressure ulcers occurred when the RTMP systems were utilized over 3 months. CONCLUSION: Pressure monitoring allowed HCPs to monitor support surface performance and employ improved pressure redistributing interventions to enhance patient outcomes in PI prevention.

1. 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: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

2. Petersen MJ, Gravenstein N, Schwab WK, van Oostrom JH, Caruso LJ. Patient repositioning and pressure ulcer risk—monitoring interface pressures of at-risk patients. J Rehabil Res Dev. 2013;50(4):477–488.

3. Behrendt R, Ghaznavi AM, Mahan M, Craft S, Siddiqui A. Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit. Am J Crit Care. 2014;23:127–133.

4. Gunningberg L, Carli C. Reduced pressure for fewer pressure ulcers: can real-time feedback of interface pressure optimise repositioning in bed? Int Wound J. 2016;13(5):774–779. doi:10.1111/iwj.12374.

5. Scott RG, Thurman KM. Visual feedback of continuous bedside pressure mapping to optimize effective patient repositioning. Adv Wound Care. 2014;3(5):376–382.

Wound—Product Selection and Innovations



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

PROBLEM: Pediatric patients develop mucositis when receiving treatments such as chemotherapy and radiation. The gastrointestinal mucosa's epithelial cells divide quickly, leading to breakdown and painful ulceration. The most common and sensitive is oral mucositis. Patients developed painful bleeding ulceration and thick mucoid saliva. Lips eventually crack and bleed. Mouth rinses containing antimicrobial, antihistamine, and analgesic medications are the mainstay for pediatric patients. These rinses are often refused related to taste or texture. Patients less than a year old are unable to use these products. Continued oral mucositis leads to increased pain and refusal or inability to eat. PROJECT OBJECTIVE: Outcomes from oral mucositis such as decreases in nutritional intake and deteriorating oral hygiene developed from the painful, bleeding ulcers and dry crusting of the mouth. Alternatives to standard treatments were necessary. Leptospermum honey was added to daily mouth care. At completion of this poster, this treatment has been used in 10 pediatric oncology patients between the ages of 9 months and 17 years. CASE SERIES: To demonstrate the improvement of oral mucositis with standard oral care and the additional use of active Leptospermum honey in 3 pediatric oncology patients. OUTCOME: The Leptospermum honey paste was easy to apply and well received by all patients. The patient received oral care every 4 hours, followed by the application of the honey paste 2 to 3 times daily. The paste was applied with a sponge swab, coating the mouth. Patients either swished and spit or had excess suctioned out. Three selected examples of the 10 patients are presented in the poster. Leptospermum honey paste proved to be effective in all participating patients. Healing observed within 3 days, and patients in all cases reported decreases in pain. Decrease in wounds and bleeding was evident in all cases within 5 days.

1. Miller M, Donald D, Hagemann T. Prevention, treatment of oral mucositis in children with cancer. J Pediatr Pharmacol Ther. 2012;17(4):340–350.

2. Molan P, Rhodes T. Honey: a biologic wound dressing. Wounds. 2015;27(6):141–151.

3. Rashad U, Al-Gezawy S, El-Gezawy E, Azzaz A. Honey as topical prophylaxis against radiochemotherapy-induced mucositis in head and neck cancer. J Laryngol Otol. 2009;123:223–228. doi:10.1017/S0022215108002478.

4. Song J, Twumasi-Ankrah P, Salcido R. Systematic review and meta-analysis on the use of honey to protect from the effects of radiation-induced oral mucositis. Adv Wound Care. 2012;25(1):23–28.

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



Rosalinda Morante, MSN, RN, CCRN, CCNS, [email protected], ICU/CVICU, Jacksonville, FL

BACKGROUND: The American Nurses Association conducted a survey on health risk and found that 42% of respondents worry about healthcare worker injury (HCWI) during patient handling (PH). While 75% reported access to PH equipment, only half reported consistent use. Most PH equipment is inefficient to use and geared toward out-of-bed mobility. Injuries during in-bed PH are now recognized as a significant source of HCWI, and PH equipment for in-bed mobility reduces risk. Objectives were to (1) reduce HCWI during in-bed repositioning and (2) increase compliance to q2h turning. METHODS: The 2014 standard of care for in-bed PH was pillows and draw sheets for turning, boosting, repositioning, and maintenance of turn angle. In January 2016, we implemented a new protocol that included the use of an in-bed PH device that served as a replacement for pillows and draw sheets. We educated all staff in the proper use of the device and monitored compliance with the new protocol. RESULTS: In 2014, we experienced 13 staff injuries that occurred during in-bed PH and our compliance to q2h turning was 22%. After implementation (through July of 2016), there were no staff injuries associated with in-bed PH while using the new protocol and our turning compliance increased to 85%. The only staff injury occurred while turning a patient and not using the new protocol. CONCLUSION: We experienced a 100% reduction in HCWIs related to in-bed PH using our new protocol. When considering both the added cost of the new PH device and the cost avoidance from prevention of HCWI, our overall return on investment (ROI) was $133,155. Our plan is to continue to track patient and staff outcomes and well as ROI related to our new process.

American Nurses Association Health Risk Appraisal (HRA). Preliminary findings October 2013-October 2014.

Fragala G, Boynton T, Conti MT, et al Patient-handling injuries: risk factors and risk-reduction strategies. Am Nurse Today. 2016;11(5):40–44.

Wound—Product Selection and Innovations



Janis E. Harrison, BSN, RN, CWOCN, CFCN, [email protected], Harrison WOC Services, Thurston, NE

CLINICAL PROBLEM: Four adults and 1 pediatric patient presented with painful trauma wounds managed in an emergency department (ED). Patient 1: right foot crush injury affecting the first and second toes. Patients 2 and 3: second-degree burns affecting the face near the eyes. Patient 4 (2-year-old): first-and second-degree burns affecting the hands and legs. Patient 5: second-degree burns affecting the right arm and hand. All patients' pain rated from 3 to 10 initially (0-10 scale). INITIAL MANAGEMENT AT ED VISIT: Patient 1: standard Polymeric Membrane Dressings (PMDs) wrapped around the toes. Patient 5: silver PMDs applied. Patients 2, 3, and 4: silver sulfadiazine (SSD) applied. CURRENT CLINICAL APPROACH: After discharge, all were referred to the outpatient wound clinic and seen within 1 to 3 days. PMDs replaced SSD to help reduce patients' wound pain. There were concerns regarding SSD migrating into patient 2's and 3's eyes and with patient 4 (2-year-old) rubbing her eyes and putting fingers in her mouth. SSD can damage eyes and mucus membranes and may be harmful if swallowed. Patients had silver PMDs applied. No further manual cleansing was required after initial removal of SSD, as PMDs continuously cleanse. Dressing changes were decreased from 2 to 3x per day with SSD to every 2 to 3 days with PMDs. PATIENT OUTCOMES: All wounds reached closure with PMDs. Pain was reduced to 3 to 0 (0-10 scale) for all patients. Once PMDs were applied, patient 4 (2-year-old) was no longer in emotional distress, stopped crying, and allowed the dressings to be changed. Reduced frequency of PMD changes reduced disruption of the wound bed. PMDs facilitated blister reabsorption, debridement, and reduced scarring. CONCLUSIONS: PMDs provided an optimal healing environment. PMDs are the standard protocol of care in the ED.

Adderley U. Managing wound exudate. Nurs Resid Care. 2010:12(5):228–232.

Weissman O, Hundeshagen G, Harats M, et al Custom-fit polymeric membrane dressing masks in the treatment of second degree facial burns. Burns. 2013;39(6):1316–1320.

Ostomy—Product Selection and Innovations



Tim Luttrell, BSN, RN, CWOCN, , Surgery, Indianapolis, IN; and Lisa Kirk, MSN, RN, CWOCN, , Surgery, Indianapolis, IN

STATEMENT OF CLINICAL PROBLEM: A vesicostomy is a urinary diversion most commonly performed in infants and young children for temporary bladder drainage. Diapers are typically used to manage the urine output. When a child reaches school age, diapering is not an effective and acceptable way to contain the drainage and odor. J. is a 7-year-old female with a history of spina bifida with neurogenic bowel and bladder. DESCRIPTION OF PAST MANAGEMENT: Attempts were made to pouch the vesicostomy, but due to the anatomical location (just above the symphysis pubis and in a deep abdominal fold) and lack of a budded stoma, pouching has not been effective. Diapers are being used to manage the drainage. J. attends school and struggles socially due to odor and leakage of urine. Her mother reports changing and washing bed linen daily. Frequent clothing changes throughout the day causes J. to miss valuable classroom time. CURRENT CLINICAL APPROACH: After conferring with the urologist, an AFM Ag dressing ribbon was tucked into the vesicostomy to wick the urine flow into the ostomy appliance. A flexible 2-piece urostomy pouching system was used. PATIENT OUTCOMES: The vesicostomy tissue remains healthy, and surrounding skin is intact. Urine is clear, with no odor. The use of the AFM Ag ribbon has been effective at keeping the urine from pooling under the wafer. There have been no urinary tract infections in the 7 months since using this method to manage the urine. CONCLUSION: The mother is having success with pouching the vesicostomy since using the AFM Ag ribbon. J. is no longer waking up wet. Laundry expenses and time have decreased substantially. J. has remained healthy and odor free. She is thriving in school and no longer feels isolated from her friends.

Doughty DB, Lightner DJ. Genitourinary surgical procedures. In:Bryant RA, Hampton BG, eds. Ostomies and Continent Diversions: Nursing Management. St Louis, MO: Mosby-Year Book; 1992:259.

Wound—Product Selection and Innovations



Cyndy Towers McCombs, BSN, RN, , Huntsville Hospital, Huntsville, AL; and Candice Cotton, MSN, RN, CWON, CFCN, , Wound clinic, Huntsville, AL

Adequate wound bed preparation is an important first step in the wound-healing process. Debridement is a necessary component of this process. It is utilized to remove necrotic tissue, thus reducing bioburden located within the wound bed and to stimulate healthy granulation tissue formation. There are many ways that debridement can be performed, most of which have aspects that make it unacceptable for nursing staff and/or patients being treated in the outpatient setting. Many debridement strategies cause pain and anxiety for the patient. It may also have an impact on clinical nursing scope of practice. Equipment logistics and cost to the facility also play a vital role in debridement strategy selection. In May 2013, our Outpatient Wound Clinic adopted the use of a fully disposable hydrodebridement system as part of our treatment protocol for debridement of burn wounds. Through literature review, we found that this type of wound debridement is underutilized by nurses within the wound care community. The collected data from our retrospective case series were obtained from treatment documentation and photographs of approximately 30 individuals ranging in ages from 16 months to 80 years. All patients included in this study were referred to our clinic for burn wound care/treatment. Our study is designed to report our experience on the effectiveness of a hydrodebridement system. It proved to be a treatment option for the removal of nonviable tissue and the stimulation of healthy granulation tissue. Through its simplicity of use, cost-effectiveness, disposability of equipment, and the patient reporting of little or no pain during the procedure, the hydrodebridement system has played, and continues to play, a vital role in optimizing positive wound-healing outcomes for the burn patient being treated in our outpatient clinical setting.

1. D'Cruz R, Martin HC, Holland AJ. Medical management of paediatric burn injuries: best practice part 2. J Paediatr Child Health. 2013;49(9):E397–E404.

2. Teot L. Surgical debridement. In: Granick M, Gamelli R, eds. Surgical Wound Healing and Management. New York, NY: Informa; 2007:91–102.

3. Jeffrey S. Debridement of pediatric burns. In: Granick M, Gamelli R, eds. Surgical Wound Healing and Management. New York, NY: Informa; 2007:53–56.

4. Poiteau M, Morel T, Benabadallah K, Guillain P. The JetOx system in care of leg ulcers: one year report. Therapeutique, 2009;16:226–229.

Wound—Evidence-Based Interventions



Donna Willemsen, BSN, RN, CWS, CWOCN, CFCN, , New Braunfels, TX

INTRODUCTION: Of the greater than 16 million people in the United States who have diabetes, 15% will develop at least one foot ulcer during the lifetime of their disease. Diabetes causes 56% to 83% of the estimated 125,000 lower extremity amputations performed annually.1 Off-loading of the ulcer area is extremely important for the healing of plantar ulcers. Inadequate off-loading of the ulcer has been proven to be a significant reason for the delay of ulcer healing. The most effective method of off-loading, which is also considered to be the gold standard, is the total contact cast (TCC).2 No prefabricated device is likely ever to match its combination of protection completely from both normal and shear forces, and it approaches as near to a guarantee of patient compliance as any off-loading technique can. Recent advances in wound dressings extend the utility of the TCC rather than replace it.3 AIMS: The aim of this poster was to illustrate the use of the TCC in a small series of patients with diabetic foot ulcers to facilitate closure. All patients have diabetes and other comorbidities that increase the challenge to successfully close their wounds. METHOD: Total contact casting was used as off-loading therapy in all patients in this case study. In some of the patients, the TCC was the only treatment provided; in others, the TCC was used in conjunction with different treatments such as hyperbaric oxygen therapy and biological skin substitutes. OUTCOME: This case series of diabetic foot ulcers demonstrates the effectiveness of how proper off-loading using the TCC, alone or in conjunction with other treatments, can result in improved patient outcomes.

1. Hess CT. Diabetic foot ulcers. Adv Skin Wound Care. 2008;21(6):296.

2. Alexiadou K, Doupis J. Management of diabetic foot ulcers. Published April 20, 2012.

3. Guyton GP. The total contact cast: indications and technique. Tech Foot Ankle Surg. 2004;3(3):186–191.

Wound—Management of Complex Wounds



Jeanette Margaret Gatan, MSN, RN, CMSRN, CWOCN, , Judith C. Landis-Erdman, BSN, RN, CWOCN, , and Ronald Rock, MSN, ACNS-BC, , Wound Ostomy Continence Nursing, Cleveland, OH

Creating an optimal environment for wound healing is critical to achieve positive outcomes in the postoperative surgical patient. Continuous wound healing prevents infection, wound stalling, and potential conversion into a chronic wound. Healthy granulation tissue within the wound bed will facilitate wound closure. The combination of 2 proposed wound care modalities in an appropriately prepared wound bed can enhance the growth of healthy granulation tissue and result in desired wound outcomes. Ovine collagen extracellular matrix (OCEM) dressing functions to encourage and support the formation of granulation tissue growth. The intact natural structure of the matrix regulates intracellular communication, provides a scaffolding to support cell growth of granulation tissue, and reduces matrix metalloproteases (MMPs). The use of negative pressure wound therapy (NPWT) dressings has been well established in facilitating tissue growth. The mechanism of cell distortion under the negative pressure results in infiltration of growth factors, increasing cell mitosis and angiogenesis, resulting in formation of granulation tissue. Excess extracellular fluid containing MMPs and inflammatory cells is removed. The concurrent use of OCEM and NPWT can provide an environment conducive for optimal wound healing to occur. Three surgical wound case studies to include abdominal and leg wounds will be presented using an OCEM dressing with an NPWT dressing, resulting in the formation of granulation tissue growth necessary for wound healing.

Bohn GA, Gass K. Leg ulcer treatment outcomes with new ovine collagen extracellular matrix dressing: a retrospective case series. Adv Skin Wound Care. 2014;27(10):448–454.

Desvigne MN. Ovine Collagen Extracellular Matrix (CECM) Dressing Assisted Closure: For the Acute Wound, Following Mohs Surgical Excision. Phoenix, AZ: English Dermatology.

Ferreras DT, Craig S, Malcomb R. Utilization of Ovine Collagen Dressing With an Intact Extracellular Matrix (CECM) Within a Dual-Protocol Algorithm to Improve Wound Closure Times and Reduce Expenditures in a VA Hospital. Alexandria, LA: Alexandria VA Wound Healing Center.

Lidden BA, Barnaby MCH. Clinical outcomes following the use of ovine forestomach matrix (endoform dermal template) to treat chronic wounds. Adv Skin Wound Care. 2013;26(4):164–167.

Vidovic G, Sykes P. The Use of an Ovine Collagen Dressing in Conjunction With Negative Pressure Wound Therapy in the Management of Chronic Diabetic Foot Ulcers. Houston, TX: University General Hospital Podiatric Surgery Residency.

Wound—Preventative Practices New



Mary Montague, MSN, RN, ACNS-BC, CWOCN, , Nursing Quality, Cleveland, OH

Development of a hospital-acquired pressure injury (HAPI) affects patients' quality of life, morbidity and mortality, hospital reimbursement, and quality reporting indicators. Research has demonstrated that moisture, friction, and shear contribute to HAPI development. Cotton linens increase skin moisture, friction, shear, and temperature. This study investigated if bed linens made from a newly developed silk-like polyester fiber affected the rate, time to development, and severity of HAPI in critically ill adult inpatients. A cluster randomized crossover design was used to explore this question in the medical intensive care units (MICUs) of a Midwest United States 1200-bed quaternary care medical center. With few exclusions, data on the rate of unit-acquired HAPI development, time to development of the first HAPI, and maximum severity of HAPI for all patients admitted to the MICU were abstracted from the electronic medical record. Mixed-effects logistic and Poisson regression models were used to evaluate differences in the prevalence and rate of occurrence. A random effect for patients was included to account for multiple admissions by the same patient during the study. Time to the first pressure ulcer was evaluated using a marginal Cox proportional hazards model, with repeated admissions from the same patient accounted for by the use of a sandwich estimator of the variance. The final analysis included 3332 MICU admissions. The experimental and control groups were similar on all demographic factors except race. Controlling for race, there was no statistically significant difference for rate, time to development, or maximum severity of HAPI. Studies conducted in other hospitals and settings have demonstrated that silk-like linens have a significant positive effect on HAPI frequency. The participating units in this study have maintained a low HAPI incidence rate, with robust pressure injury prevention initiatives sustaining this metric. Further research is warranted in sites with a higher incidence of HAPIs.

Coladonato J, Smith A, Watson N, et al Prospective, nonrandomized controlled trials to compare the effect of a silk-like fabric to standard hospital linens on the rate of hospital-acquired pressure ulcers. Ostomy Wound Manage. 2012;58(10):14–31.

Doughty D. Prevention and early detection of pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):76–78.

Reich NG, Myers JA, Obeng D, Milstone AM, Perl TM. Empirical power and sample size calculations for cluster-randomized and cluster-randomized crossover studies. PLoS ONE. 2012;7(4):e35564.

Twersky J, Montgomery T, Sloane R, et al A randomized, controlled study to assess the effect of silk-like textiles and high-absorbency adult incontinence briefs on pressure ulcer prevention. Ostomy Wound Manage. 2012;58(12):18–24.

Wound—Product Selection and Innovations



Suzie Ehmann, DPT, PT, CWS, CLT-LANA, , Edema Management, Albemarle, NC; and Marta Ostler, PT, CWS, CLT, , Northeast Wyoming Wound Clinic, Sheridan, WY

PURPOSE: Compression applied to the limb is the standard of care for the management of venous leg ulcers (VLUs).1 Mechanism of the impact of compression on healing VLU has focused primarily on the impact that compression has on the underlying venous anatomy.2 A new type of compression therapy, characterized as “fuzzy wale” compression, which when applied directly in contact with the wound bed, has shown dramatic impact on healing times in previously recalcitrant wounds. Five detailed case studies to be presented, demonstrating outcomes including change in wound size and time to wound closure. METHODS: Five patients between the ages of 64 and 91 years (1 man, 4 women) presented to separate outpatient wound/lymhedema clinics with nonhealing ulcerations of varying durations (6 months-19 years). All patients received “fuzzy wale compression” directly in contact with the wound bed along with various secondary dressing to maintain a moist wound environment. Additional compression therapy applied over the “fuzzy wale compression” as consistent with past plan of care. Wound measurements and photos to be provided. FINDINGS: In each case, decrease in wound size and improvement in appearance with each dressing change were noted. Previously, recalcitrant wounds healed with only the addition of the “fuzzy wale” compression directly on the wound bed. It was noted that reepithelization was observed along the “furrows” created by the fuzzy wale compression. CONCLUSIONS: Compression applied to the leg has been shown to have positive impact on venous circulation; however, little has been mentioned in the literature about the impact of compression applied directly to the wound base. The ability of the fuzzy wale technology to apply compression in various patterns directly to the wound bed and along wound margins shows improvements in wound healing and ultimately wound closure. Resolution of induration and fibrosis in the periwound tissue, as well as epithelial migration, is evidence of increased perfusion promoting wound healing.

1. Ratliff C, Yates S, McNichol L, Gray M. Compression for primary prevention, treatment, and prevention of recurrence of venous leg ulcers. J Wound Ostomy Continence Nurs. 2016;43(4):347–364.

2. Chi YW, Raffetto JD. Venous leg ulceration pathophysiology and evidence based treatment. Vasc Med. 2015;20(2):166–181.

3. Wu SC, Crews RT, Najafi B, Slone-Rivera N, Minder JL, Andersen CA. Safety and efficacy of mild compression (18-25 mm Hg) therapy in patients with diabetes and lower extremity edema. J Diabetes Sci Technol. 2012;6(3):641–647.

Wound—Management of Complex Wounds



Michelle Beck, BSN, RN, CWOCN, , AMU, Shelbyville, IN; and Autumn Buckler, RN, WCC, , ICU, Shelbyville, IN

INTRODUCTION: This case study discusses 3 wounds as a result of 1 motorcycle accident involving 2 patients. Necrotic tissue and bioburden are challenges that affect wound-healing outcomes. The goal of this case series was to evaluate the DACC (dialkylcarbamoyal chloride) technology to facilitate the removal of necrotic tissue, manage the bioburden, and improve healing times in 3 acute traumatic wounds while in different healthcare settings. METHOD: DACC is a fatty acid derivative that binds irreversibly with bacteria and renders them inert and unable to replicate through a physical mode of action called hydrophobicity. Bacteria are naturally hydrophobic and are bound to other hydrophobic substances. This allows the entrapment of the bacteria in the DACC-coated dressing, allowing the removal of the bacteria with each dressing change. The DACC technology dressings used in this case series is an absorbent hydropolymer gel border dressing that facilitates autolytic debridement and changed every 3 to 4 days. RESULTS: One wound was a left knee blunt force trauma that began as a blood-filled blister that developed into necrotic tissue. One wound was a full-thickness burn sustained from the tailpipe of the motorcycle against the leg. Wound 3 was a traumatic full-thickness left medial calf wound sustained from dragging on the asphalt. All wounds showed improvement with the use of the DACC hydropolymer dressings to facilitate debridement and reduction of bioburden. The DACC hydropolymer dressings proved to be easy to use, decreased pain with dressing changes, and improved the healing of all wounds. CONCLUSION: DACC hydropolymer dressings were clinically effective in 3 traumatic wounds in the removal of necrotic tissue, reduction of bioburden (as evidenced in the reduction of wound exudate and improvement in healthy granulation tissue), preventing infection, and improved healing outcomes.

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

Kammerlander G, Locherer E, Süss-Burghart A, von Hallern B, Wipplinger P. Non-medicated dressing as an antimicrobial alternative in wound management. Die Schwester Der Pfleger. 2007;46:84–87.

Wound Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2016.

Wound—Preventative Practices New



Meredith Cooper, BSN, CCRN, , ICU, Baton Rouge, LA; John Godke, MD, FACCP, , Baton Rouge, LA; and Jobe Nasca, BSNc, RN, , Intensive Care Unit, Baton Rouge, LA

INTRODUCTION: Our 24-bed medical-surgical critical care unit observed a sharp increase in hospital-acquired pressure injury (HAPI) incidence rates from 4.52 per 1000 patient-days (2014-2015) to 13.58 per 1000 patient-days (February-May 2016). This culminated in a total of 35 HAPIs, 26 of which were deep tissue injuries (DTIs). A significant problem with support surfaces was changed immediately. A multidisciplinary team utilized the Plan, Do, Study, Act cycle to implement a prevention bundle and test of change. SUMMARY OF INTERVENTIONS: Bundle interventions included a 5-layer soft silicone border sacral dressing, off-loading heel boots, and an air displacement positioning system with fluidized positioner. After literature review, at-risk patients identified included patients with expected intensive care unit (ICU) length of stay more than 72 hours, body mass index more than 40 or less than 19, vasopressor or paralytic use, any pressure injury (PI) present on admission or history of PI, Braden Scale score less than 13, or RASS more than +2. The preventive 5-layer sacral dressing, left in place for up to 7 days unless soiled, was implemented over the first month. Next, positioning with a foam wedge or pillow was changed to positioning with an air displacement positioning system with fluidized positioner. Staff were educated on all shifts. Each discipline evaluated the new system. Skin and risk assessments every 12 hours continued throughout the project. RESULTS: All patients receiving the complete bundle were PI free. Three patients in cardiogenic shock who did not receive the complete bundle developed PIs during the project. The total cost of the bundle per patient including (2) heel boots, (1) positioning system, and (1) sacral dressing was $242.18. In comparison, the treatment cost of stage II HAPI is estimated up to $10,000. The preventative cost for 41 ICU patients is roughly equivalent to the cost of treating a single-stage II HAPI.

Hyun S, Li X, Vermillion B, et al Body mass index and pressure ulcers: improved predictability of pressure ulcers in intensive care patients. Am J Crit Care. 2014;23(6):494–501.

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. Perth, Western Australia: Cambridge Media; 2014.

Spetz J, Brown DS, Aydin C, Donaldson N. The value of reducing hospital-acquired pressure ulcer prevalence. J Nurs Adm. 2013;43(4):235–241.

Wound—Product Selection and Innovations



Faith Singleton, BA, BSN, RN, MSN, CWON, , Enterstomal Department, Charleston, SC

This is a single case study of a 54-year-old diabetic male admitted to the hospital with initial diagnosis of chronic kidney failure, heart failure, and uncontrolled diabetes. Patient also had a chronic nonhealing diabetic foot ulcer for over 6 years. The vascular surgeon consulted the wound care nurse for topical wound care treatment. Recent MRI did not show osteomyelitis, so surgery was ruled out. However, it was also determined that patient would need dialysis after discharge from the hospital. Discharge planning was involved in arranging this with an outpatient dialysis clinic. The scheduled visits 3 times weekly to get dialysis would likely interfere with home health visits for wound care. It was therefore imperative to try to rid the wound of the biofilm, odor, and adherent slough. The goal of the wound care nurse was to have the wound bed prepared prior to discharge from the hospital. Wound care treatment plan involved a collagenase enzymatic debrider applied to the wound bed twice daily, along with daily hydrotherapy lavage used at the bedside. There was a remarkable dramatic improvement in the wound bed within 3 days. There was less than 5% slough, no odor, and pink wound bed. Patient was discharged home with wound care orders for bid wound gel with damp normal saline gauze. The patient was instructed on wound care prior to discharge and would be able to change dressing on the days the home health nurse was unable to see him.

Continence—Issues in Bladder and Bowel Continence Management



Judith J. Stellar, MSN, CRNP, PPCNP-BC, CWOCN, , Nursing, Philadelphia, PA

Infants with complex anomalies affecting continence can pose many challenges to the health care team. As these infants grow and progress through childhood and adolescence, they pose even greater challenges from both developmental and physiologic standpoints. This session explores the developmental, educational, medical, and surgical needs of pediatric patients with a urinary diversion as they progress from infancy through adolescence. In addition to addressing developmental needs, discussion includes a review of various congenital and acquired conditions necessitating urinary and diversions. An overview of surgical procedures is presented since a good understanding of the unique anatomy is crucial in planning care. A case scenario format is used to describe patient approaches for a variety of conditions in 5 unique cases: bladder/cloacal exstrophy, spina bifida, and 2 oncologic conditions resulting in pelvic radiation sequelae. Proper transitioning through one phase of development to another is important, and the WOC nurse plays a vital role in creating smooth transitions. School, sports, body image, peer, and partner concerns are addressed. Fostering adaptation through each stage of development is a focus of care. A review of a wide array of ostomy appliances and accessories and tricks of the trade is also presented.

Wound—Dermatological Management/Issues



Anita Shelley, MSN, RN, CNS, CWOCN, , Indianapolis, IN; and Tracy Swift, BSN, RN, CPN, , and May Ishikawa, BSN, RN, CWOCN, , Quality & Safety, Indianapolis, IN

July 2016, an 11-year-old morbidly obese female was admitted to a pediatric intensive care unit (PICU) in a Midwestern tertiary children's hospital. One week prior to admission, she was without symptoms. First day hospitalized, she was taken to the operating room to have a chest tube placed for pleural effusion, central venous access, and biopsies of abdominal masses. She was diagnosed with Burkett's lymphoma, a highly aggressive B-cell neoplasm that comprises approximately 30% of pediatric lymphomas in the United States, with an estimated incidence of 3 cases per million per year with 4:1 male dominant ratio in both children and adults. This 11-year-old's hospitalization has been complicated by septic shock, severe tumor lysis syndrome requiring hemodialysis, multiple infections, respiratory failure from pulmonary edema, typhlitis, severe exfoliative rash, severe mucositis, pancytopenia, and hemodynamic instability. PICU physicians consulted Plastics/Burn, Dermatology, and WOC teams for treatment options for severe skin desquamation. Dermatology biopsied her skin and results revealed chemotherapy-induced desquamation. Literature reviews shows that chemotherapy-induced acral erythema (CIAE) is an uncommon and dramatic reaction to high-dose chemotherapy, characterized by painful erythema of the palms and soles with possible bullae formation and desquamation. This preteen had 25% total body surface area affected on her back, in skin folds, posterior neck, thighs, and buttocks, with painful denuded patchy skin, erythema, and bullae formation. No literature was found for this severe skin desquamation related to chemotherapy. Multidisciplinary collaboration endorsed the WOC team to take primary lead in skin management. Prevention of infections, skin injuries, and pain management were priorities. Treatment included pain medication prior to bathing with soft foaming wash cloths, humectant and emollient application to maintain moisture, hydrophilic wound dressing to open wounds, and a silver absorbent pad to wick away drainage. WOC direction and vigilant nursing care generated positive outcomes.

Freedman AS, Aster JC. Epidemiology, clinical manifestations, pathologic features and diagnosis of Burkitt lymphoma.∼76. Literature review current though September 2016. Published 2016. Accessed November 1, 2016.

Werchniak AE, Chaffee S, Dinulos JG. Methotrexate-induced bullous acral erythema in a child. J Am Acad Dermatol. 2005;52:S93–S95.

Wound Treatment Associate Task Force. Position statement about the role and scope of practice for wound care providers. http:// Published 2011. Accessed November 2, 2016.



Adeline Galvez, BSN, RN, CWON, [email protected], Wound and Ostomy Nursing, Fort Worth, TX; and Lisa Stewart, BSN, RN, CWOCN, [email protected], Wound and Ostomy Nursing, Fort Worth, TX

BACKGROUND: Wegener's granulomatosis is a necrotizing small vessel vasculitis that can affect any organ in the body but mainly affects respiratory tract, kidneys, joints, skin, and eyes.1 Nonetheless, cutaneous ulcers are uncommon initial manifestation.2 Dermatologic manifestations maybe treated with topical steroids or surgery in cases of severe tissue damage due to necrosis.3 This retrospective case study demonstrates the use of noncontact low-frequency ultrasound (NLFU)a in combination with an enzymatic debrider in a patient with necrotic ulceration to buttocks related to Wegener's granulomatosis. Treatment effectiveness was evaluated using the absence of necrotic tissue, increased granulation, and decrease in wound size. Treatment was continued until the wound bed was 100% granulated. NLFU utilizes sound wave energy to mechanically stimulate cells. This results in reduction of bacteria, disruption of biofilm, as well as improved blood flow due to vasodilation.4 Enzymatic debriders degrade necrotic tissue without harming viable granulation tissue. Over the years, various enzymes have been used for debridement. Enzymatic debriders works by selectively cleaving the collagen bonds that hold necrotic tissue to the wound bed.5 CASE PRESENTATION: The patient was a 48-year-old male admitted for multiple painful rectal ulcerations. Comorbidities include diabetes mellitus type 2. Upon arrival, wound bed was covered with necrotic tissue. NLFU treatments were administered daily for 5 days, in conjunction with enzymatic debridement × 3 days. After 5 days, NLFU was administered 3 times per week until the patient was discharged. After day 3, necrotic tissue was absent in the wound bed. Wound-related pain was resolved. DISCUSSION: This case study demonstrated that treatment of Wegener's necrotic ulcerations with the combination of NLFU and enzymatic debridement resulted in successful removal of necrotic tissue and granulation of the wound bed. An additional benefit was avoidance of the need for surgical debridement.

aMIST Ultrasound Healing Therapy, Alliqua BioMedical, Yardley, Pennsylvania.

1. Fortin PM, Tijani AM, Bassett K, Musini VM. Intravenous immunoglobulin as adjuvant therapy for Wegener's granulomatosis. Cochrane Database Syst Rev. 2009;(3):CD007057.

2. Daoud MS, Gibson LE, DeRemee RA, et al Cutaneous Wegener's granulomatosis: clinical, histopathologic, and immunopathologic features of thirty patients. J Am Acad Dermatol. 1994;31:605–612.

3. Ali AlMatrooshi ME chief ed, Elston DM. Dermatologic manifestation of granulomatosis with polyangiitis (Wegener granulomatosis).

4. Ramundo J, Gray M. Enzymatic wound debridement. J Wound Ostomy Continence Nurs. 2008;35(3):273–280.

5. Unger PG. Low frequency, noncontact, nonthermal ultrasound therapy: a review of the literature. Ostomy Wound Manage. 2008;54(1):57–60.

6. Bryant RA, Nix DP. Acute and Chronic Wounds Current Management Concepts. 4th ed. chap 17.

Wound—Product Selection and Innovations



Rene Amaya, MD, FAAP, CWSP, , Houston, TX

Wound management in neonatal and pediatric patients poses multiple challenges to the wound care provider. Safety and efficacy are 2 significant barriers when addressing the wound care needs in this fragile population. In this case series, pediatric patients ranging from premature neonates to a teen paraplegic patient presented to our practice for management of severe full-thickness wounds of various etiologies. A new decellularized human skin allograft was applied to these wounds to determine safety and efficacy towards granulation and closure of the complex wounds. The allograft replaces human dermis with human dermis to most closely approximate the structure and function of the native tissue it is replacing. It is not derived from fetal foreskin fibroblasts, bovine collagen, urinary bladders, or placentas. Rather than providing a sacrificial collagen, the allograft provides a receptive matrix that becomes integrated into the host tissue. In each case, following effective debridement of nonviable tissue, the allograft was applied to the clean wound bed without the need for surgical services or general anesthesia. The dressing was left in place as per manufacturer's recommendations with regular monitoring to assess for side effects or complications. In each case, all wounds were effectively closed and epithelialized following application of the allograft. No signs of tissue rejection, infection, or other localized wound complications were encountered. This case series illustrates the safe and effective use of a new decellularized human allograft for wound closure in neonatal and pediatric patients.

Greaves NS, Benatar B, Baguneid M, Bayat A. Single-stage application of a novel decellularized dermis for treatment-resistant lower limb ulcers: positive outcomes assessed by SIAscopy, laser perfusion, and 3D imaging, with sequential timed histological analysis. Wound Repair Regen. 2013;21(6):812–822.

Wound—Management of Complex Wounds



Maureen W. McCarthy, MSN, CWON, AGNP-C, , Karen Baggetta, BSN, RN, CWON, , and Briann Velazquez, BSN, RN, CWOCN, , General Surgery, Boston, MA

Complex wounds are a challenging part of the WOC nurses' role. The following case studies examine large, unique wounds that were effectively managed by the WOC nurse using modes of negative pressure wound therapy (NPWT) while isolating enteric fistulas. Outcomes include wound healing, drainage containment, preservation and restoration of periwound skin, and expedited preparation for skin grafting. Digital wound photos are included. A 75-year-old patient admitted March 24, 2016, with enteroatmospheric fistula s/p ventral hernia repair for incarcerated small bowel on March 14, 2016. History included surgical repair of hip fracture on March 11, 2016, rheumatoid arthritis, morbid obesity, and ventral hernia with multiple past repairs. Abdominal wound was treated with NPWT, isolating the fistula using the technique of wrapping a circle of dressing foam in the drape, surrounding the fistula, and sealing with barrier rings. NPWT continued until the wound was ready for split-thickness skin graft; NPWT continued on graft until epithelialization. Finally, a fistula pouch was used, and the patient was discharged to rehab on May 25, 2016. A 40-year-old patient underwent surgery on May 2, 2016, for penetrating pancreatic injury (stab wound), complicated by the formation of enteric fistula. The wound was treated with multiple modalities. NPWT was utilized, and the fistula was isolated using a ring of foam, while other wounds were dressed on the abdomen simultaneously (including pouching leaking feeding tube). A fistula pouch with access window, wound packing, attached to low wall suction was also used. The patient was discharged to long-term acute care (LTAC) on June 23, 2016, with a wound care plan. The patient had surgery on October 12, 2016, for fistula repair. A 72-year-old patient with a history of coronary artery disease s/p myocardial infarction, ischemic cardiomyopathy, chronic obstructive pulmonary disease, Crohn's disease, and colectomy underwent surgery on August 26, 2016, for adnexal mass, complicated by enterotomy requiring small bowel resection, and reanastomosis. Course was complicated by intra-abdominal sepsis requiring multiple surgeries. The WOC nurse was consulted on September 1, 2016, for an enteroatmospheric fistula within the wound. NPWT was utilized for this large wound while isolating the multiple fistulas within the wound. The patient was transferred to LTAC with detailed instructions for wound care.



Beverly Coleman, BSN, CRRN, WCC, , Spinal Cord Injury, Dallas, TX; and Michelle Mendez, MD, , Spinal Cord Injury, Dallas, TX

PAST MEDICAL HISTORY: Aortic valve replacement in 1984, which required long-term blood thinners; coronary artery bypass graft in 1984; AFib with myocardial infarction in 1984 that resulted in spinal cord injury; transurethral bladder resection in 2010; left-hand mass in 2012; cancer mass in the left hand in 2013; excision of the left-hand mass in October 2014; and split-thickness skin graft in December 2014. Growth on the hand since 2009: diagnosis small cell carcinoma—the mass increased in size in 1 year. October 2014: Excision of left-hand mass, involvement of the fourth and fifth Metacarpal Joint surgical wound 12 × 5-cm tendon and bone exposed in the wound bed. The surgical team planned to return the patient to the operating room (OR) 2 more times postexcision of the mass. October 20, 2014: Left-hand wound debridement. Plastic surgical team treatment plan to place Integra in 1 week. The patient reported significant pain, and the patient given hydromorphone IV. Prealbumin: 14 (October 14, 2014); C-reactive protein: 2.81 (October 14, 2014); October 16, 2014: partial thromboplastin time: 72.4; H Sec: 25.1-36.5. October 29, 2014: Initial negative pressure wound therapy (NPWT) with porcine small intestinal submucosa triple-layer matrix. November 5, 2014: Second application of porcine small intestinal submucosa triple-layer matrix and NPWT. Wound bed with granular tissue—the plastic surgical team treatment plan changed due to wound progress; plan for skin graft alone. Patient-reported pain reduced. November 12, 2014: Plastic surgical MD assessment noted left upper extremity: clean looking wound of the left hand, no purulence/cellulitis. Increased granulation tissue over previously exposed bone of third MC + small part of extensor tendon to MF. November 27, 2014: Fourth porcine small intestinal submucosa triple-layer matrix placed. NPWT discontinued. Wound bed with hypergranular tissue in periwound—silver nitrate applied—no pain reported. The team continued with secondary closure with porcine small intestinal submucosa triple-layer matrix for 2 more applications to closure. Plastic surgical MD recommended to continue plan the split-thickness graft. December 5, 2014: Split-thickness graft—the patient sent to the OR. December 10, 2014: Surgical site healed and ready for therapy.

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



Evan Call, MS, CSM, , and Rachel Walker, RN, , Microbiology, Centerville, UT

Medical compression therapy relies on a simple and efficient mechanical principle: the application of an elastic garment such as socks, stockings, pantyhose, or bandages around the leg to improve the overall hemodynamics by increasing venous blood flow, decreasing venous blood volume, reducing reflux in diseased veins, and reducing elevated venous pressure. The purpose of this study was to compare the mechanical properties of 2 competitive compression wrap systems, bandage A and bandage B. The static stiffness index and compression provided by the 2 systems were measured on 8 healthy volunteers using a PicoPress. Moisture vapor transmission and moisture vapor runoff were measured using standard methods. There was no significant difference in compression between bandages A and B when the subjects were at rest (P = .19) or standing (P = .48). However, bandage A did show a larger increase in compression from resting to standing than bandage B, which corresponds to the higher stiffness of bandage A. The moisture vapor transmission test evaluates the rate of moisture transmission through the bandage. The average MVTR of bandage A was 3964.2 ± 627.9 g/m2/d, and the average MVTR of bandage B was 1805.4 ± 274.2 g/m2/d. The average MVTR of bandage A was significantly higher than that of bandage B (P = .008). Moisture runoff tests the moisture absorption prior to water running off the bandage. The foam under layer of bandage A absorbed significantly much more water than the under layer of bandage B (31.99 ± 0.96 mL vs 0.98 ± 0.36 mL, P < .001 [α= .05]). Overall, when comparing the mechanical properties of 2 competitive compression wrap systems, there was no significant difference in their stiffness, nor the amount of compression they apply. However, bandage A had a significantly higher MVTR and moisture absorption than bandage B.

Standard atmospheres for conditioning and/or testing. ISO 554:1976E. International Organization for Standardization, Geneva, Switzerland. 01 August 1976.

Guide to expression of uncertainty in measurement. ISO 98-3:2008. International Organization for Standardization, Geneva, Switzerland October 2008.

Compression bandage test Partsch method. EC Service Protocol 605.002 Rev 2 EC Service, Centerville, Utah. 19 January 2016.

Partsch H. The static stiffness index: a simple method to assess the elastic property of compression material in vivo. Dermatol Surg. 2005;31:625–630.

Partsch H, Clark M, Bassez S, et al Measurement of lower leg compression in vivo: recommendations for the performance of measurements of interface pressure and stiffness. Dermatol Surg. 2006;32:224–233.

Partsch H. Physics of Compression. Conference Matters.

Mosti G. Stiffness of compression devices. Veins Lymphatics. 2013;2(1):1–2.

Khaburi JA, Dehghani-Sanij AA, Nelson EA, et al Measurement of interface pressure applied by medical compression bandages. Paper presented at: International Conference on Mechatronics and Automation; August 7-10, 2011.



Honey Lyn Lerias, BSN, RN, CWOCN, , and Sherrie Ingles, RN, CWOCN, , Patient Education, Detroit, MI

Patients with wounds and new ostomy can be challenging because of the discomfort and anxiety they are experiencing. Pharmaceutical agents may bring them relief, but they may not be effective in all cases. A randomized study was conducted among 50 patients with wounds and new ostomy over a 6-week period with the use of aromatherapy to optimize comfort in conjunction with pharmaceutical agents. Lavender, an essential oil that is used as a natural relaxation agent, was utilized in this study to evaluate its effectiveness in pain management and relaxation. Lavender was administered through inhalation by placing 1 to 2 drops in a cotton ball and placing it at the patient's bedside an hour prior to dressing change or ostomy care education. The goal of the study was to evaluate if aromatherapy in conjunction with pain medication can be more effective in decreasing pain and anxiety or if it can be utilized in lieu of the pharmaceutical agents. Outcomes of the study did confirm that these patients would still require their scheduled pain medication and/or antianxiety agents. Ninety percent of the total patients surveyed still have the same pain score and anxiety level without their scheduled pain medication. Altogether, using lavender as an aromatherapy agent cannot in itself minimize pain and anxiety in this specific patient population. The same study did confirm that aromatherapy with lavender in conjunction with pharmaceuticals can decrease pain more and promote relaxation in 75% of the patient surveyed. Promoting positive patient experience is our goal as a WOC nurse, and it is very good to know that there are resources that we can incorporate in our practice such as aromatherapy to achieve this outcome.

Ostomy—Stomal/peristomal complications



Angela Graham, BSN, RN, CWOCN, , Education, Birmingham, AL

AIM: To describe use of ceramide-infused skin barriers as a part of ostomy management in the home care setting. STATEMENT OF PROBLEM: Ostomates experience many physical and psychological difficulties after returning home from the hospital,1 and skin complications frequently occur within the first 3 months after surgery. During this vulnerable time, home care clinicians can help improve patient outcomes as they are providing care for new ostomates. METHOD: Three consecutive case studies selected from a single home health practice. All case studies include patient history, initial treatment modalities, and use of a ceramide-infused ostomy barrier in the overall plan of care. CONCLUSION: Home care nurses have a very important role in promoting peristomal skin health and preventing peristomal skin complications. Use of a ceramide-infused skin barrier, as part of the overall ostomy care plan, resulted in positive patient outcomes for these patients in the home care setting. Additional studies are needed to determine the use of a ceramide-infused skin barrier in the home care setting.

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

2. Ratliff C. Factors related to ostomy leakage in the community setting. J Wound Ostomy Continence Nurs. 2014;41(3):249–253.

3. Salvadalena G. The incidence of stoma and peristomal complications during the first 3 months after ostomy creation. J Wound Ostomy Continence Nurs. 2013;40(4):400–406.

Wound—Management of Complex Wounds



Kersten Reider, BSN, RN, CWOCN, , West Reading, PA

Enteroatmospheric fistulas (EAFs) are a common complication of open abdomen bowel surgery, with an estimated 2% to 50% of patients developing fistulas postsurgery.1 The presence of an EAF increases patient morbidity and provides a challenge to the wound care team.2 Traditionally, management of EAFs has involved placing large fistula management pouches over the wound to collect and contain effluent. However, more recent techniques isolate the fistula and apply negative pressure wound therapy (NPWT) to the rest of the wound.2,3 We isolated an EAF and applied NPWT to a large abdominal wound to promote granulation tissue formation and decrease wound dimensions. A fistula management pouch was utilized for several months to encompass the wound and contain effluent. This method proved to be ineffective. The fistula was then isolated utilizing a collapsible EAF isolation device and an ostomy appliance to contain effluent. The wound was then managed with NPWT. Closed incision negative pressure therapy (ciNPT) was used for 5 days following abdominal wall reconstruction. A 54-year-old morbidly obese female was admitted with a small bowel obstruction and large ventral hernia. The patient underwent an exploratory laparotomy with lysis of adhesions and ventral hernia repair with mesh placement, and she ultimately developed an EAF. Contraction of wound edges and presence of granulation tissue were observed after NPWT use in the wound bed around the isolated EAF. At 7 months after presentation, the patient underwent abdominal wall reconstruction and closure, followed by 5 days of postoperative ciNPT. The patient was successfully discharged home under the care of visiting nurses. The application of the collapsible EAF isolation and effluent containment devices in conjunction with NPWT produced positive patient outcomes, including patient satisfaction, decreased financial burden, promotion of wound healing, and ultimately wound closure.

Becker HP, Willms A, Schwab R. Small bowel fistulas and the open abdomen. Scand J Surg. 2007;96:263–271.

Timmons J, Russell F. The use of negative-pressure wound therapy to manage enteroatmospheric fistulae in two patients with large abdominal wounds. Int Wound J. 2014;11:723–729.

Cro C, George KJ, Donnelly J, Irwin ST, Gardiner KR. Vacuum assisted closure system in the management of enterocutaneous fistulae. Postgrad Med J. 2002;78:364–365.



Elizabeth McElroy, CRNP, CWS, CWOCN, , West Reading, PA

Recent studies have reported on clinical benefits of using adjunctive negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) on complex wounds. We present a case series demonstrating successful outcomes using advanced wound care modalities. Patient 1, a 63-year-old morbidly obese female, presented with an infected right thigh excision of a massive localized lobule. Following surgical debridement of an infected hematoma, local wound packing using 0.25% acetic acid–soaked gauze was applied. After insufficient wound improvement, NPWTi-d (instillation of 0.25% acetic acid solution with 5-minute dwell time, followed by 6 hours of NPWT) was used for 1 week, followed by 3 weeks of NPWT. A split-thickness skin graft (STSG) was applied. NPWT was used to bolster the STSG for 1 week, and the patient was discharged with a healed wound. Patient 2, a 58-year-old male, presented with a chronic lower extremity wound with exposed hardware. After hardware removal and surgical debridement, NPWT was applied for 2 days, followed by NPWTi-d (instillation of saline with 10-minute dwell time, followed by continuous NPWT every 3.5 hours) for 21 days. Treatment was changed to local silver packing and topical antibiotic. The wound healed, and the patient was discharged 57 days after surgery. Patient 3, a 71-year-old female, presented with right-hand swelling and pain secondary to a soft tissue infection. Following antibiotic treatment and several tenosynovectomy procedures, NPWTi-d (saline instillation with 2-minute dwell time, followed by 2 hours of NPWT) was applied for 5 days. After the wound displayed significant granulation tissue formation, the patient was discharged home with NPWT. Wound closure was observed 4 weeks post-NPWT application. In all 3 cases, combined use of advanced wound care treatments resulted in positive clinical outcomes.

Wound—Product Selection and Innovations



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

PROBLEM: Chronic wounds are not a common occurrence in the pediatric population. Wounds in healthy children usually heal quickly and without complication. However, wound healing can be delayed by factors such as an underlying disease process, administration of certain medications, poor nutrition, or an immunocompromised state. Wounds that develop in patients with these risk factors do not always respond to standard wound treatments and can become chronic. PROJECT OBJECTIVE: Noncontact low-frequency ultrasound therapy (NLFU) was begun for wounds that showed less than 50% improvement after 1 month of treatment. There were no exclusions for therapies used prior to the initiation of NLFU. CASE SERIES: NLFU was used to treat wounds with less than 50% improvement after 1 month of treatment in 3 pediatric cases. Wounds varied in type. Patients ranged from 5 to 17 years of age. OUTCOME: NLFU was used for chronic wounds in 3 pediatric cases. All patients achieved improvement in the wound healing as evidenced by complete closure or 50% improvement within 2 weeks of treatment with NLFU. Decreased slough and decreased pain and/or discomfort during dressing changes were observed as well.

Wound—Management of Complex Wounds



Donna Willemsen, BSN, RN, CWS, CWOCN, CFCN, , New Braunfels, TX

PURPOSE: To demonstrate the effectiveness of dehydrated human amnion/chorion membrane (dHACM) 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. INTRODUCTION: 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 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 cesarean section, to donate their placentas, and the processed tissues are safe, effective, and minimally manipulated allografts that are intended for homologous use. METHODOLOGY: Five case studies are presented including photos, patient histories, and progression of healing with dHACM applications. Included are the following chronic wounds: arterial, venous, diabetic, surgical, and pressure ulcer. CONCLUSION: 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. 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. Ophthalmol 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(1):58–75.



Rosemary Hill, BSN, RN, CWOCN, CETN (C), , Ambulatory Program, North Vancouver, BC, Canada

AIM: Debridement is essential to wound bed preparation, making it a priority intervention in the management of acute and chronic wounds.1 Maintaining moisture balance is essential for wound healing.2 Selecting a dressing that helps address patient-centered concerns such as pain and exudate may optimize the patient-clinician collaboration.3 The purpose of this case series was to evaluate the impact of a methylene blue and gentian violet (MBGV) antibacterial foam dressing on devitalized tissue and moisture balance on 3 chronic and 3 acute wounds. METHOD: All wounds (surgical excisions, a neuropathic foot ulcer, abdominal, and 2 pressure injuries) were managed with the MBGV dressing. The dressing was changed every 2 to 3 days. For the abdominal wound, the dressing was used to remove devitalized tissue prior to negative pressure wound therapy (NPWT). Additional therapies (eg, pressure redistribution, compression) were used when indicated to address the underlying cause. Digital images and wound measurements were taken to assess for condition of periwound skin and changes in wound size and amount of devitalized tissue. RESULTS: Five of the 6 wounds reduced in size and exhibited a decrease in the percentage of devitalized tissue during the use of the dressing. One of the surgical wounds exhibited a reduction of devitalized tissue from 95% to 50% of the wound surface area in 2 days, allowing NPWT to be initiated. The periwound skin remained intact in all cases. Use of the MBGV dressing in two 90-year-old individuals supported removal of devitalized tissue and enhanced granulation tissue and improvement in pain management where previously they had been unable to tolerate NPWT. IMPLICATIONS: Results of this case series (removal of devitalized tissue and optimizing moisture balance) indicate the MBGV dressing is a suitable choice for acute and chronic wounds with devitalized tissue and varying levels of wound exudate.

Strohal R, Apelqvist J. Dissemond J, et al. EWMA document: debridement: an updated overview and clarification of the principle role of debridement. J Wound Care. 2013;22:S1–S52.

Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation. Adv Wound Care. 2015;28(10):466–476.

Corbett LQ, Ennis WJ. What do patients want? Patient preferences in wound care. Adv Wound Care. 2014;3(8):537–543.

Wound—Product Selection and Innovations



Rosemary Hill, BSN, RN, CWOCN, CETN (C), , Ambulatory Program, North Vancouver, BC, Canada

BACKGROUND: This poster demonstrates the successful outcome for 6 surgical patients at high risk for wound complications. In spite of advances in aseptic technique, surgical site infections (SSIs) continue to be a major source of patient morbidity and represent considerable burden to the health care system worldwide. In fact, the development of an SSI can be associated with costs as high as $20,000 per patient.1 There is emerging literature suggesting the benefits of application of negative pressure wound therapy (NPWT) to reduce SSIs. It has been proposed that negative pressure stimulates wound healing by improving perfusion to the wound. This has been seen in open wounds and now is more recently being applied to closed surgical wounds thought to be at high risk for infection or dehiscence.2 Another theoretical advantage of incisional NPWT is prevention of subcutaneous seromas/hematomas that secondarily become infected.3 METHOD: Six patients deemed to be at high risk for surgical site complications had NPWT applied to their closed incision. The surgical cases included 5 abdominal surgeries, a bariatric case, and 1 orthopedic case. Four cases included individuals with ostomies. Bonds et al noted that obesity, colonic surgery, operative time, and the presence of a stoma to be significant contributors to SSIs. Risk factors included 1 or more of the following: obesity, systemic infection, wound infection, ostomies, hemodynamic instability, and disease conditions including malignancy and Crohn's disease. RESULTS: In all instances, the patients avoided development of SSIs or incisional complications. This poster demonstrates with photos the visual appearance of the incision lines on postoperative day 5. CONCLUSION: These 6 case studies suggest that further exploration is necessary with respect to the use of incisional NPWT, as our experience demonstrated avoidance of SSIs in high-risk patients undergoing major abdominal and orthopedic surgery.

Bonds AM, Novick TK, Dieter BS, Araghizadeh MD, Olson CH. Incisional negative pressure wound therapy significantly reduces surgical site infection in open colorectal surgery. Dis Colon Rectum. 2013;56:1403–1408.

Vargo D. Negative pressure wound therapy in the prevention of wound infection in high risk abdominal wound closures. Am J Sur. 2012;204:1021–1024.

Blackham AU, Farrah JP, McCoy TP, Schmidt BS, Shen P. Prevention of surgical site infection in high-risk patients with laparotomy incisions using negative-pressure therapy. Am J Sur. 2013;205:647–654.

Ostomy—Stomal/Peristomal Complications



Elizabeth Taggart, BSN, RN, CWOCN, , Memorial Medical Center, Springfield, IL; and Karen Spencer, BN, ET, , Libertyville, IL

STATEMENT OF CLINICAL PROBLEM: Maintaining peristomal skin integrity is a concern for ostomy patients. The literature suggests that as many as two-thirds of people with an ostomy will develop a serious peristomal skin complication.1 Peristomal skin complications can impact health-related quality of life, health economics, and clinical outcomes. DESCRIPTION OF PAST MANAGEMENT: All patients are exposed to PMASD, MARSI, and skin occlusion related to barrier use. Choosing the correct ostomy barrier is the responsibility of the WOC nurse not only to ensure a good seal around the stoma but also to minimize the impact that leakage, barrier removal, and barrier occlusion have on the peristomal skin. CURRENT CLINICAL APPROACH: There are 2 categories of skin barriers, extended wear and regular wear, chosen based on absorption and adhesion.2 To help maintain peristomal skin health, WOC nurses should consider new product options in their decision making to be more proactive in their practice. SELECTED PATIENT OUTCOMES: The 3 cases include a urostomy, ileostomy, and colostomy. In each case, the peristomal skin was ulcerated at the onset of care, and the ostomy management was modified to include use of a ceramide-infused skin barrier. Skin condition improved or resolved, and in 2 cases, product utilization was reduced. CONCLUSIONS: WOC/ET nurses are challenged with managing peristomal skin complications, and patients are negatively impacted. Adopting ceramide-infused skin barriers can help provide positive outcomes. Beyond case studies, further research is required to support this new product option.

Lyon C, Smith A. Abdominal Stomas and Their Skin Disorders. London, England: Martin Dunitz Ltd; 2001:IX.

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

Wound—Management of Complex Wounds



Peg Manochi, BSN, RN, CWCN, , Cherry Hill, NJ; and Stacy Stevenson, RN, WCC, , NPWT, Norristown, PA

STATEMENT OF PROBLEM: The treatment of chronic wounds is a billion dollar industry. We spend upwards of $25 billion a year treating them.1 The challenges for patients suffering from chronic wounds after discharge from the hospital are many. Returning to a productive life poses unique challenges that involve mobility, cost control, and maintaining dignity all while continuing to keep the wound on a healing trajectory and preventing costly complications and readmissions. DESCRIPTION OF CLINICAL APPROACH: This patient presented with a stage 4, mid-thoracic pressure injury measuring 5.8 × 2.1 × 1.1 cm, with circumferential undermining after a long hospital stay for acute myocardial infarction, cardiogenic shock, ventilator-dependent respiratory failure, acute renal failure, hemorrhagic shock, and Serratia and Citrobacter pneumonia requiring the use of extracorporeal membrane oxygenation therapy in the intensive care unit for 38 days. Advanced wound care dressings were ineffective in healing the wound. A portable, personal negative pressure wound therapy (NPWT) device was used upon discharge home. The patient also required a defibrillator vest that exerted pressure on the wound site. RESULTS: The wound healed in a short amount of time with no complications. The unique challenges of the defibrillator vest and the NPWT device were dealt with expertly by the home care nurse and the wound care nurse. CONCLUSIONS: By implementing the use of a portable, personal NPWT device, the patient was able to return to a productive, rewarding life and maintain activities of daily living. Home care nurses and the wound care nurse from the medical device company collaborated to troubleshoot, educate, and follow up on his progress and solve any issues his unique circumstance presented. The patient is grateful to be alive and celebrate the “best Father's Day ever” without a wound!

1. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ Publication No. 11-0053-EF.

Ostomy—Product Selection and Innovations



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

WOC nurses are taught to use convexity with caution. It is commonly suggested that convexity is not to be used in the first few days and weeks postostomy creation due to concerns of mucocutaneous separation. In the past, selecting a convex appliance typically referred to a 1- or 2-piece rigid convex barrier that helped the flush stoma to become more prominent. Recently, the addition of soft convexity to the market has helped address many ostomy challenges. However, convex appliances now come in a variety of shapes, heights, depths, and flexibility. This poster demonstrates how a flexible cone-shaped convexity product was utilized in a 6 client case study series to prevent ostomy leakage and improve the quality of life for the ostomate with challenging abdominal contours. The case studies include urostomy, ileostomy, and colostomy clients experiencing decreased wear time despite a prominent end stoma or proximal loop stoma. In addition, the poster demonstrates how a thorough assessment of the abdominal contours assists in selection of an appropriate deep flexible cone-shaped convex appliance (Hoeflok et al, 2013). Studies have shown that peristomal skin complications range from 6% to 80% for all ostomates, resulting in more products being purchased to compensate for leakage, creating a financial burden. By utilizing a deep flexible cone-shaped convexity, wear time can be improved and skin breakdown can be prevented, which ensures that quality of life is maintained. CONCLUSIONS: Leakage for ostomates affects not only their quality of life but may also cause skin breakdown and an increased financial burden. This poster demonstrates how a deep flexible cone-shaped convexity is used to conform to the abdominal contours despite at times having a prominent end ostomy or loop ostomy.

Hoeflok J, Kittscha J, Purnell P. Use of convexity in pouching: a comprehensive review. J Wound Ostomy Continence Nurs. 2013;40(5):506–512. doi:10.1097/won.0b013e3182a219b7.

Ostomy and convexity. http:// Accessed October 2016.

Richbourg L, Thorpe JM, Rapp CG. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs. 2007;34(1):70–79. doi:10.1097/00152192-200701000-00011.

Wound—Dermatological Management/Issues



Rene Amaya, MD, FAAP, CWSP, , Houston, TX

The first step in wound care is debridement, which can be done in a number of ways. However, with pediatric patients, the debridement method of choice must not only be effective but also as gentle as possible. A new burn and wound dressing has a surfactant component that provides unique micelle properties. This dressing is also cell-friendly, biocompatible, and 100% water soluble. This combination allows for gentle dressing application and changes, as the water-soluble translucent gel dissolves for less crusting, fast dressing changes, and less pain. Due to the unique properties of the dressing, it was evaluated on pediatric patients with wounds with nonviable, necrotic tissue that required autolytic debridement. A convenience sample of patients whose injuries required debridement was included in the study. Wounds of various etiologies were included in the study. At presentation, the burn and wound dressing was applied directly to the wound and covered with a secondary dressing. The parents were then instructed to do the dressing changes at home between weekly clinic visits. At the weekly clinic visits, mechanical debridement was performed on all loose, nonviable tissues. Time to resolution was tracked. The burn and wound dressing with micelle technology promoted a moist wound-healing environment and less painful dressing changes. The dressing changes were easy for the parents. No adverse events, such as skin irritation, were seen.

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

Sibbald RG, Williamson D, Orsted HL, et al Preparing the wound bed—debridement, bacterial balance, and moisture balance. Ostomy Wound Manage. 2000;46(11):14–37.



Rene Amaya, MD, FAAP, CWSP, , Houston, TX

The skin is the largest organ of the body, and it performs several vital functions. Mature skin forms a physical barrier, provides UV protection, prevents invasion of pathogens, and regulates body temperature and sensory perception. Skin maturation is a process that starts at the moment of delivery and ends in the first year of life. However, premature infants experience complications related to skin immaturity. Neonatal skin is fragile, and the immature epidermis and stratum corneum inhibit the skin's ability to regulate body temperature, maintain water and electrolyte balance, prevent infection, and protect against absorption of toxic substances. Due to the fragile nature of their skin, it is imperative that it is protected against potential skin breakdown caused by epidermal stripping, extravasation, wound breakdown, and excoriation. The purpose of this study was to evaluate the use of a cyanoacrylate no-sting liquid skin protectant on the skin of neonates. A convenience sample of patients was selected. The cyanoacrylate no-sting liquid skin protectant was applied to the damaged skin and to the at-risk skin. Standard wound care was also carried out. The time to resolution of skin breakdown was tracked, and any adverse events were noted. Within a few applications, the symptom of the damaged skin was resolved, which is of upmost importance in caring for this high-risk patient population. During the course of this study, no adverse events were seen. The cyanoacrylate no-sting liquid skin protectant has become a standard usage item in our formulary.

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

Continence—Evidence-Based Treatment and Management



Jerra Sullivan, MSN, RN, CWOCN, , Northeast Hospital, Beverly, MA; and Tanya Martel, MSN, FNP-BC, CWOCN, , Winchester, MA

As the body's largest organ, the skin requires vigilance, particularly in high-risk patients such as the elderly and the young. The skin serves 3 main functions: protection, regulation, and sensation. Since the skin is the primary line of defense against mechanical forces, chemical elements, and external organisms, maintaining skin integrity is of vital importance. For patients who have incontinence issues, repeated and extended exposures to urine and stool, which contain alkaline chemicals and enzymes, make maintaining skin integrity a challenge and can lead to incontinence-associated dermatitis. The weakening of the skin's barrier function makes it more susceptible to friction, erosion, and bacteria. Moisture-related skin damage from exposure to caustic bodily fluids has been associated with pain and secondary infection. A variety of barrier products are available to protect the skin from these corrosive fluids, so purpose of this case series study was to evaluate a skin barrier with added micronutrition on patients at high risk for skin breakdown. For this evaluation, patients who were seen for incontinence referrals were evaluated. A plan of care for the skin was given, which included the application of the barrier with micronutrition. The health and quality of the skin were assessed. Overall, the skin barrier with micronutrition effectively maintained the integrity of the at-risk skin.

Young DL, Chakravarthy D. A controlled laboratory comparison of 4 topical skin creams moisturizing capability on human subjects. J Wound Ostomy Continence Nurs. 2014;41(2):168–174.

Gao Y, Wang X, Chen S, Li S, Liu X. Acute skin barrier disruption with repeated tape stripping: an in vivo model for damage skin barrier. Skin Res Technol. 2013;19(2):162–168.

Lu N, Chandar P, Tempesta D, Vincent C, Bajor J, Mcguiness H. Characteristic differences in barrier and hygroscopic properties between normal and cosmetic dry skin, part I: enhanced barrier analysis with sequential tape-stripping. Int J Cosmet Sci. 2014;36(2):167–174.

Wound—Preventative Practices New



Jerra Sullivan, MSN, RN, CWOCN, , Northeast Hospital, Beverly, MA; and Tanya Martel, MSN, FNP-BC, CWOCN, , Winchester, MA

Per the new NPUAP (National Pressure Ulcer Advisory Panel) guidelines, a pressure injury (PI) is defined as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device resulting from intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. There are a number of interrelated factors that may significantly impact a patient's PI risk. One major contributor in predicting PI risk is the microclimate (temperature and humidity) present between the skin-bed/dressing/clothing interface. In addition to temperature and humidity, shear stress and friction are 2 important factors to consider. Due to the positioning of the patient, the sacral area is under the largest amount of stress from both friction and shear. Studies have shown that multilayer dressings can provide additional features to promote microclimate control via temperature management, relative humidity and moisture absorption, and resistance to friction and shear stress. The purpose of this study was to evaluate a new silicone faced sacral foam dressing for PI prevention. The silicone faced foam dressing was applied onto patients at high risk for PI determined by their Braden Scale score. Pressure injury data were then collected to determine the effectiveness of the new silicone faced foam dressing.

National Pressure Ulcer Advisory Panel. Press release April 2016. http://

International Review. Pressure Ulcer Prevention Pressure, Shear, Friction and Microclimate in Context [Brochure]. London, England: Wounds International; 2010.

Hess CT. Did you know? The difference between friction and shear. Adv Skin Wound Care. 2004;17(5):222.

Black J, Clark M, Dealey C, et al Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J. 2014;12(4):484–488. doi:10.1111/iwj.12197.

Wound—Product Selection and Innovations



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

PROBLEM: An otherwise healthy 2-year-old girl reached into hot glue, resulting in extensive second- and third-degree hand burns. An otherwise healthy teenaged boy had a skateboard accident, leaving a full-thickness 2.5-cm diameter left medial epicondyle area wound. A healthy middle-aged man dropped the first 2 fingers of his left hand into a whirling table saw blade, slicing the middle finger from the tip to the first joint and completely shattering the distal phalange of the index finger while nearly severing the fingertip. These trauma patients needed immediate pain relief without incapacitating narcotics so that they could resume their active lives. PAST MANAGEMENT: The girl initially received prescription creams and homeopathic remedies for her burns. Despite acetaminophen + codeine, ibuprofen, and lavender oil, dressing changes (3-4 per day) were excruciating. The teenager received oral antibiotics, ibuprofen, and creams and was referred to a plastic surgeon for debridement. The emergency department physician cleaned and loosely sutured the man's finger wounds, provided narcotic pain relievers, and referred him to a hand surgeon. NEW APPROACH: Polymeric membrane dressings (PMDs) were designed to decrease pediatric burn patients' pain by continuously cleansing wounds, being nonadherent, and balancing moisture. They subdue and focus the nociceptor response, which can dramatically relieve pain. All topical treatments were discontinued, including rinsing at dressing changes, for all 3 patients. Saturated PMDs were simply removed and replaced. PMDs were provided to patients' families, who found dressing changes to be pain-free. PATIENT OUTCOMES: After only 7 hours, the girl had clean, unmacerated, uninflamed wound beds. Pain reliever use decreased and healthy granulation tissue formed. All 3 patients' wounds closed quickly, without surgical intervention and with minimal scars. CONCLUSIONS: These patients had extremely painful trauma wounds that initially seemed unresolvable without surgical intervention. Through use of PMDs, all 3 were spared surgery, further pain, and physical and emotional scarring.

Davies SL, White RJ. Defining a holistic pain-relieving approach to wound care via a drug free polymeric membrane dressing. J Wound Care. 2011;20(5):250–254 passim.

Benskin LL. Polymeric Membrane Dressings for topical wound management of patients with infected wounds in a challenging environment: a protocol with 3 case examples. Ostomy Wound Manage. 2016;62(6):42–62. http://

Weissman O, Hundeshagen G, Harats M, et al Custom-fit polymeric membrane dressing masks in the treatment of second degree facial burns. Burns. 2013;39(6):1316–1320. doi:

Kim YJ, Lee SW, Hong SH, Lee HK, Kim EK. The effects of PolyMem(R) on the wound healing. J Kor Soc Plast Reconstr Surg. 1999;26(6):1165–1172.

Benskin L. Excellent healing of pediatric wounds using polymeric membrane dressings. J Wound Ostomy Continence Nurs. 2009;36(3S):S14.

Wound—Management of Complex Wounds



Janis E. Harrison, BSN, RN, CWOCN, CFCN, , Harrison WOC Services, Thurston, NE

The use of a collagen/oxidized regenerated cellulose (ORC) dressing in a series of complex wounds is presented. Case 1, an 89-year-old male with a history of diabetes mellitus, peripheral vascular disease, and chronic obstructive pulmonary disease, presented with a traumatic wound on the dorsal anterior of the left great toe present for 7 days. The wound was debrided and covered with a collagen/ORC dressing and a silver finger/toe dressing. After 5 weeks, the wound was fully closed. Case 2, a 42-year-old male with a history of obesity and spina bifida, presented with a pressure ulcer on the right ischial tuberosity present for several weeks. Following debridement, the wound was covered with a collagen/ORC dressing and a secondary foam dressing. The wound closed within 21 days. Case 3 was a 75-year-old male with a history of alcohol use, diabetes mellitus, coronary heart disease, peripheral vascular disease (PVD), and hypertension. He presented with a venous leg ulcer on the posterior lower left leg present for 17 days. The wound was debrided and covered with a collagen/ORC dressing, nonadhesive silver foam dressing, and a 4-layer compression wrap. The wound healed within 17 days. Case 4 was a 93-year-old male with a history of coronary heart disease, PVD, hyperlipidemia, atrial fibrillation, peripheral arterial disease, mitral valve insufficiency, osteoarthritis, congestive heart failure, and second and third metatarsal amputation. He had a chronic ulcer present for 8 months on the right lateral foot near the fifth metatarsal and osteomyelitis. The patient was treated with intravenous and oral antibiotics, debridement, and application of a collagen/ORC dressing and negative pressure wound therapy. After 1 month, treatment was changed to a collagen/ORC dressing, silver hydrofiber dressing, and gauze wrap. The adjunctive treatment with a collagen/ORC dressing resulted in wound healing in 3 out of 4 cases.

Wound—Dermatological Management/Issues



Traci Tillery, MSN, FNP-BC, CWOCN-AP, CFCN, , Specialty Services, Rome, GA

PURPOSE: The efficacy of treatment options for wounds caused by cystic acne remains a challenge for many. With the ever-evolving advanced wound care products being implemented, in this one case, effective results were achieved. METHODS: This photographic case study highlighted the management of wounds caused by refractory cystic acne with the application of Gentian Violet/Methylene Blue Polyurethane (GV/MB PU) antibacterial foam. This teenage male was introduced to our practice after 3 years of previous multiple failed therapies. Therapies to treat the refractory cystic acne included acne treatment face wash, Manuka honey, antibiotic washes, and multiple topical therapies. Systemic treatments included extended periods of prednisone, various combinations of antibiotics, and 2 rounds of an oral retinoid. Holistic approaches were also attempted, which included eliminating foods such as dairy, gluten, corn, and sugar. Initially, a silicone contact layer was used and held in place by a compression garment. Due to silicone contact layer sliding and not staying over the wounds, the dressing was changed to silver foam dressing. RESULTS: After 4 weeks of wound management and no improvement, dressing was changed to using GV/MB PU antibacterial foam changed every 3 to 5 days. After 2 weeks of using GV/MB PU antibacterial foam, there was a reduction in pain medication. The patient reported feeling better and the oral retinoid was stopped. Seven weeks later, the patient no longer needed wound dressing therapy. He was able to wear clothes without any dressings underneath and was able to take a shower for the first time in 3 years. CONCLUSION: Wounds caused by refractory cystic acne can be a challenging skin alteration to treat. GV/MB PU antibacterial foam was used in the successful resolution of cystic acne wounds.

Wound—Preventative Practices New



Traci Tillery, MSN, FNP-BC, CWOCN-AP, CFCN, , Specialty Services, Rome, GA; and Tracy Floyd, LPN, , Rome, GA

PURPOSE: Despite many interventions and support surfaces, pressure injuries (PIs) continue to occur. One study shows that health care providers (HCPs) are unaware of the actual pressure redistribution effects of repositioning interventions that allow patients continued high pressure exposure,1 leading to PI development. METHODS: To better understand patients' pressure exposure, real-time pressure monitors (RTPMs) were placed on critical care unit (CCU) mattresses for 5 months. HCPs utilized this visualization when repositioning patients. Peak pressures were recorded when HCPs repositioned both before and after interventions. A number of hospital-acquired pressure injuries (HAPIs) were also gathered for the 5 months prior to using the system as well as for the 5 months the systems were used. RESULTS: A total of 518 repositions were observed. Prior to assessing peak pressures with the RTPMs, the peak pressures averaged 53 mm Hg. When RTPMs were utilized for repositioning, the average peak pressures dropped to 45 mm Hg. HAPIs also reduced when the RTPMs were utilized. Five months prior to use, 7 HAPIs were reported. With the RTPMs in use, only 2 HAPIs were acquired in the CCU. CONCLUSION: Visualizing pressure exposure in the CCU has led to more effective repositioning and less HAPIs.

Petersen MJ, Gravenstein N, Schwab WK, van Oostrom JH, Caruso LJ. Patient repositioning and pressure ulcer risk—monitoring interface pressures of at-risk patients. J Rehabil Res Dev. 2013;50(4):477–488.

Behrendt R, Ghaznavi AM, Mahan M, Craft S, Siddiqui A. Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit. Am J Crit Care. 2014;23:127–133.

Gunningberg L, Carli C. Reduced pressure for fewer pressure ulcers: can real-time feedback of interface pressure optimise repositioning in bed? Int Wound J. 2016;13(5):774–779. doi:10.1111/iwj.12374.

Scott RG, Thurman KM. Visual feedback of continuous bedside pressure mapping to optimize effective patient repositioning. Adv Wound Care. 2014;3(5):376–382.

Wound—Management of Complex Wounds



Annielyn Azor-Ocampo, BSN, RN, CWOCN, , Lincoln, NE

CLINICAL PROBLEM: A review of patient charts (n = 6) was conducted with various types of wounds not responding to typical wound care products, common diagnoses of hypertension, hyperlipidemia, respiratory insufficiency, malnutrition, and anemia in relation to other systemic factors affecting wound healing. Patients' age ranged from 28 to 90 years. PAST MANAGEMENT: Wound care products utilized to promote wound healing include low air loss therapy and fluid simulation support surfaces. Patient A: Stage 4 pressure injury to coccyx managed by calcium alginate, hypochlorous acid. Patient B: Stage 4 pressure injury to coccyx with exposed bone managed by antimicrobial barrier silver dressing. Patient C: Deep tissue injury to coccyx managed by balsam of Peru, castor oil ointment. Patient D: Full-thickness nongranulating perineal wound related to trauma from vehicular accident managed by hypochlorous acid. Patient E: Stage 4 pressure injury to coccyx managed by sodium hypochlorite acid. Patient F: Full-thickness wound to the left lower leg from hematoma with fat necrosis managed by sodium hypochlorite acid. CURRENT APPROACH: Use of NLFU as an adjunct treatment to wound care; initial wound volume ranged from 12 to 146 cm2. Patient A: NPWT, 3 NLFU treatments for 1 week. Patient B: NPWT, 10 NLFU treatments for 3 weeks. Patient C: Enzymatic debrider, 5 NLFU treatments for 1.5 weeks. Patient D: Mafenide acetate cream, 5 NLFU treatments for 1.5 weeks. Patient E: NPWT, 2 NLFU treatments. Patient F: NPWT, 13 NLFU treatments for 4 weeks. OUTCOMES: Average wound volume reduction at 60%. Three patients with an average of 76% wound volume reduction, and 1 patient with 42% reduction after 2 NLFU treatments in spite of being 1 week apart from initial treatment. CONCLUSIONS: The addition of NLFU as an adjunct treatment to standard of care for treating various types of wounds was found to be highly effective and provided positive outcomes and reduced wound volumes.

Seth AK, Mustoe TA, Galiano RD. Noncontact, low-frequency ultrasound as an effective therapy against pseudomonas aeruginosa-infected biofilm wounds. Wound Repair Regen. 2013;21(2):266–274.

Ocampo A. Use of noncontact low frequency ultrasound to accelerate healing of pressure ulcers in high acuity rehabilitation patients. J Wound Ostomy Continence Nurs. 2015;42(5):S1–S74.

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



Dennis West, PhD, , Dermatology and Pediatrics, Chicago, IL

The aim of this study was to evaluate evidence for prevention of transepidermal water loss (TEWL) by comparison of 4 dimethicone-containing barrier cream cloth products. METHODS: Thirty adult volunteers of mixed sex, age, and race had daily application of each product to a 1.5 × 1.5-in area of skin where artificial urine at pH 10.28 was applied for 7 days in random assignment to sites using an occluded patch (Finn Chambers on Scanpor tape). Sodium lauryl sulfate 1% was applied in a similar manner as the positive control. A negative control (no chemical irritant application) also was randomly assigned and measured. All test sites were scored by blinded, trained, visual assessors for evidence of irritation, including erythema, papules, edema, and vesicles. RESULTS: After daily applications of the artificial urine, only one product showed no net skin water loss (TEWL = g/h/m2) over the 7-day study (statistically significant using Tukey's pairwise comparison of test products, 95% confidence means). DISCUSSION: Evidence gained from this testing further demonstrates that skin barrier efficacy is dependent on the entire final product formulation and specifically does not necessarily correlate with the percentage concentration of dimethicone. A product with inadequate skin barrier efficacy is more likely to not allow achievement of institutional compliance with IAD guidelines and, of course, less likely to serve the needs of the patient. Despite product variability in dimethicone concentration, it proved to be an independent determinant for skin barrier efficacy. CONCLUSIONS: This study underscores the importance of evaluating product performance characteristics for similarly marketed barrier products. It remains for the practitioner and the user to be able to determine that the selected product provides the expected skin barrier effectiveness, a product characteristic that is not communicated to a user by simply reading the concentration of ingredients on the product label.

Gray M, Bliss DZ, Doughty DB, et al Incontinence associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34:45–54.

Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15:170–175.

Beeckman D, Verhaeghe S, Defloor T, Schoonhoven L, Vanderwee K. A 3-in-1 perineal care washcloth impregnated with dimethicone 3% versus water and pH neutral soap to prevent and treat incontinence-associated dermatitis. J Wound Ostomy Continence Nurs. 2011;38(6):627–634.

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(3):303–315.

Larner J, Matar H, Goldman VS, Chilcott RP. Development of a cumulative irritation model for incontinence-associated dermatitis. Arch Dermatol Res. 2015;307(1):39–48.


PRACTICE INNOVATION ABSTRACTSWound—Product Selection and Innovations



Kristen Thurman, PT, CWS, , Rosalyn Jordan, MSc, BSN, RN, CWOCN, WCC, , and Evan Call, MS, , Washington, DC

PURPOSE: For over a decade, the Support Surface Standards Initiative (S3I), a subcommittee of the National Pressure Ulcer Advisory Panel (NPUAP), has coordinated the development of a uniform terminology, test methods, and reporting standards for support surfaces. This work will provide an objective means for evaluating, contrasting, and comparing support surface characteristics. METHODS: Vocabulary was improved using the S3I process. “Terms and Definitions” were developed by a group of support surface experts, and consensus on the final draft was reached after an extensive review of the survey results. This was published in 2007. Laboratory test methods, test fixtures, and laboratory testing were then performed in a number of testing facilities. All tests were validated, and repeatability was tested in 3 different laboratories before the tests were deemed satisfactory for presentation to the voting group of experts for approval. After the initial S3I approval, the vocabulary and test methods were submitted to the Rehabilitation Engineering and Assistive Technology Society of North America/American National Standards (RESNA/ANSI) for a collaborative comment period and voting. When approved by RESNA/ANSI, all were released to the International Standards Organization (ISO) for endorsement and publication as a standard. RESULTS: To date, the ISO has approved and published: • Vocabulary; • Standard Protocol for Measuring Immersion in: Full Body Support Surfaces; • Standard Protocol for Measuring Heat and Water Vapor Dissipation Characteristics of Full Body Support Surfaces—Body Analog Method; • Standard Protocol for Measuring Heat and Moisture Dissipation Characteristics of Full Body Support Surfaces—Sweating Guarded Hot Plate (SGHP) Method. DISCUSSION: Clinicians will benefit from having support surface characteristics presented in a consistent manner to assist with matching those characteristics to individual patient needs. Standards will empower consumers and serve as a product development guide for manufacturers, enhancing quality assurance in the manufacturing process.

American National Standards Institute. American National Standard for Support Surfaces—Volume 1: Requirements and Test Methods for Full Body Support Surfaces. Washington, DC: American National Standards Institute. RESNA SS-1:2014; 2015-03-02.

ANSI/RESNA. SS-1 Support Surfaces. Section 1 Vocabulary. Arlington, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2014.

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: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

National Pressure Ulcer Advisory Panel. Support surface standards initiative. http:// Accessed September 10, 2015.

National Pressure Ulcer Advisory Panel. Terms and definitions related to support surfaces. http:// Accessed January 27, 2014.

Ostomy—Clinical Outcomes



Dona Isaac, MSN/ED, CWCN, COCN, , Gastric Mixed Tumor & Colorectal, New York, NY

PROBLEM: According to the literature, early discharges have been favored to improve readmission and reduce mortality rate (Silow-Carroll, Edwards, & Lashbrook, 2011). To facilitate this process, health care professionals need to incorporate effective teaching strategies for the client's education and coordinate care within the health care continuum. As the length of stay becomes increasingly shorter at this Cancer Center, the WOC nurse needs to be creative in assisting new ostomates in basic ostomy education prior to discharge. Mobile-based technology is providing clients with increased power over their care. To expedite early discharge, the WOC nurse decided to use videotaping as an adjunct tool for new ostomates to master and review basic ostomy care after discharge. INTERVENTION: The WOC nurse is responsible for providing new ostomates with different resources necessary to meet their learning needs and implement interactive and practice-based learning strategies to help them after surgery. Over the past year, the WOC nurse implemented the use of videotaping for the return demonstration of the pouching system change using each client's smart device or tablet. Using the client's device has allowed the WOC nurse to structure learning for each client under 10 minutes. This interactive resource has been a key element for clients to reinforce basic knowledge in ostomy education. Of the 20 clients who were contacted via telephone, 18 followed self-care practice and admitted that this valuable resource reinforced the basic skills of the pouching system change that they learned in the hospital. However, only 2 patients said they did not review the video footage because they were overwhelmed with their new stoma. CONCLUSION: This simple and creative tool of videotaping has been an effective adjunct strategy to reinforce and enhance new ostomates' education in achieving basic ostomy care after discharge.

Silow-Carroll S, Edwards J, Lashbrook A. Reducing hospital readmissions: lessons from top-performing hospitals. http://∼/media/files/publications/case-study/2011/apr/1473_silowcarroll_readmissions_synthesis_web_version.pdf. Published 2011.

Wound—Preventative Practices New



Jennifer Bart, MSN, RN, CWOCN, , Aimee Sheddan, BSN, RN, CWOCN, CFCN, , and Cearie Balkcom, BSN, RN, CWOCN, , Gainesville, FL

Every registered nurse learned how to properly stage pressure injuries according to the National Pressure Ulcer Advisory Panel guidelines in their nursing school curriculum. Applying that knowledge in everyday practice on a consistent basis was found to be problematic for the nurses at this large, southeast academic hospital. Nurses faced 2 main challenges. First, challenge was erroneously staging wounds that were not caused by pressure. In addition, wounds caused by pressure were misclassified. Without proper identification and staging of wounds, a prompt and effective plan of care for patients with pressure injuries cannot occur. Facility-acquired pressure injuries have ominous implications for the patient and the hospital. Increased patient morbidity and medical costs for the patient; and erroneous benchmarking, reimbursement, and legal issues for the hospital are just some of the implications. The WOC nurses' job was to go back to the basics and retrain 2500 nurses. The WOC nurses, recognizing the importance of correct staging, developed a reliable staging algorithm for the nurses to use during monthly prevalence. Even the unit OWLs (ostomy, wound liaisons), who are specially trained in wounds and ostomies, had many issues with identifying and staging pressure injuries accurately. The average accuracy rate for these specially trained nurses from February to July in 2015 was 84%. The accuracy rate goal was 90% or higher. The Pressure Ulcer Algorithm was taught to these specially trained nurses as an adjunctive tool to use during monthly prevalence. After implementing this tool for 6 months, the accuracy rate of staging improved by 14%. The algorithm was concluded to be an effective tool for nurses to correctly and accurately identify and stage pressure injuries. The algorithm will be incorporated into the electronic medical record for all nurses to use at this facility.

The National Pressure Ulcer Advisory Panel. NPUAP pressure injury stages. http:// Accessed June 19, 2016.

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: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

Patton RM. Is Diagnosis of pressure ulcers within an RN's scope of practice? Am Nurse Today. 2010;5(1):20.

Young D, Shen J, Estocado N, Landers M. Financial impact of improved pressure ulcer staging in the acute hospital with use of a new tool, the NE1 Wound Assessment Tool. Adv Skin Wound Care. 2012;25(4):158–166.

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



Sherry Lynn Werth, MSN, RN, CWOCN, , Nursing Education and Research, Lansing, MI

PURPOSE: Moisture-associated skin damage (MASD) is defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.”1 The prevalence of incontinence-associated dermatitis (IAD) reported in the literature range from approximately 5% to 36% in acute care sittings. This author was unable to find studies reporting the prevalence of MASD in the acute care sitting. The purpose of this project was to determine the prevalence of MASD at one level 1 trauma center in the Midwest. It was determined the most appropriate time to collect MASD prevalence data was concurrently with the quarterly Pressure Ulcer Prevalence Survey (PUPS). The PUPS team consists of 40 registered nurses. The institutional review board deemed this project to be quality improvement and patient consent was not needed. OBJECTIVE: The objective was to determine the prevalence of MASD during the PUPS. During this survey, all adult patients are asked to participate. The patient's skin is assessed from head to toe, and all pressure ulcers are recorded. An MASD data collection tool was developed by the WOC nurse. The tool was filled out only for the patients with MASD. The data collected included the patient's age, sex, and whether the condition was hospital acquired. Data were also collected regarding anatomical location of the skin damage and treatment(s) in use at the time of assessment. OUTCOMES: Data were collected quarterly for 1 year. The number of patients assessed each quarter was between 335 and 383, with a mean of 366.5. The results for IAD were determined separately from the other causes of MASD. The mean of the 4 quarters for IAD was 2.3% and MASD was 2.1%.

Gray M, Black JM, Baharestani MM, et al Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233–241. doi:10.1097/WON.0b013e318215f798.

Continence—Issues in Bladder and Bowel Continence Management



Dawn Engels, MSN, RN, CWOCN, CWCN-AP, CNS, , CNS/WOC Department, Greensboro, NC; Tamara Caple, MSN, RN, MBA, NEA, , Medical-Renal Department, Greensboro, NC; Barbara Deskins, MSN, RN-BC, , Clinical Support/Nursing Administration, Greensboro, NC; Connette Gill, MSN, RN, , Medical-Renal Department, Greensboro, NC; Danyel Johnson, MSN, RN, CNN, CNS, , Greensboro, NC; and Melissa Morgan, MSN, RN, CIC, CSPDT, , and Margaret Steelman, BSN, RN, , Infection Prevention, Greensboro, NC

Clostridium difficile infections (CDIs) are a significant safety issue and impact patient morbidity and mortality. Prevention of Healthcare Onset Clostridium difficile infection (HOCDI) transmission has become a top priority for healthcare organizations. In an effort to decrease HOCDIs within our organization, an interprofessional team collaborated to develop a CDI Prevention Bundle. Bundle methodology has demonstrated success in decreasing healthcare-associated infections such as central line–associated bloodstream infections and ventilator-associated pneumonia. Bundles standardize practices and ensure evidence-based care. The CDI Prevention Bundle contains specific interventions to address patient screening on admission and/or when symptoms first appear, appropriate timely disinfection of the environment, equipment and supplies, patient/family education in CDI transmission prevention, and hand hygiene practices. Extensive efforts were made to ensure the bundle could be integrated into the daily workflows of nursing staff. An inpatient nursing unit was selected to pilot the project. Staff nurses were instrumental in providing constructive feedback to make the necessary adjustments that would ensure successful execution. Modifications occurred over several months after interventions were trialed. After rigorous auditing and consulting with nursing staff on the pilot unit, a final CDI Prevention Bundle was established and ready for organization-wide implementation. The process of creating a CDI Prevention Bundle provided an opportunity for many disciplines to work together towards a valuable goal, keeping patients safe from harm during their hospitalization. Collaboration between physicians, infection prevention specialists, clinical nurse specialists, WOC nurses, environmental services, and nurses resulted in a process that will impact length of stay, mortality, and patient satisfaction. As with all bundles, this CDI initiative is multifaceted and multitiered. Audits will assess compliance with use of the new system. The facility will assess if a reduction in HOCDI rates is achieved by comparing monthly CDI rates to prebundle rates to determine if there is a decrease.

Cohen SH, Gerding DN, Johnson S, et al Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–455.

Guillemin I, Marrel A, Beriot-Mathiot A, et al How do Clostridium difficile infections affect nurses' everyday hospital work: a qualitative study. Int J Nurs Pract. 2015;21(S2):38–45.

Keddis MT, Khanna S, Noheria A, Baddour LM, Pardi DS, Qian Q. Clostridium difficile infection in patients with chronic kidney disease. Mayo Clin Proc. 2012;87(11):1046–1053.

Mermel LA, Jefferson J, Blanchard K, et al Reducing Clostridium difficile incidence, colectomies, and mortality in the hospital setting: a successful multidisciplinary approach. Jt Comm J Qual Patient Saf. 2013;39(7):298–305.

Wound—Product Selection and Innovations



Juvy Montecalvo Acosta, DNP, RN, ANP-BC, CWCN, , Barnegat, NJ

BACKGROUND: In 2006, the Centers for Medicare & Medicaid Services (CMS) identified hospital-acquired pressure ulcer (HAPU) as a “never event.” This lead to reimbursement restriction to HAPU-related treatment. The increased number of HAPUs, financial impact of the reimbursement restrictions, and high cost of specialty surface rental for pressure ulcer prevention generated urgency from senior leadership of a community hospital to implement a comprehensive pressure ulcer prevention program that instituted a low air loss bed replacement program. DESIGN AND METHODS: This study employed a retrospective chart review of HAPU occurrences on the year before implementation and a year after the program was implemented. Statistics reported through Quality Management Services using a monthly pressure ulcer incidence studies were utilized. Data collected included the stage of pressure ulcer and the clinical area where the HAPU was developed. A pressure ulcer incidence rate was entered through MED-CALC. INTERVENTION: There were 5 medical-surgical units included in this study. All 5 medical-surgical units that had the traditional foam hospital mattress were replaced with 190 low air loss mattresses. A low air loss mattress is a support surface that redistributes pressure. This change was conducted due to a high incidence of HAPUs 1 year prior to implementation. RESULTS: A total of 67 HAPUs were identified 1 year prior to implementation; a year after the replacement program was implemented, there were 28 HAPUs discovered. Preimplementation incidence rate was 0.04373; 1-year postimplementation incidence rate was 0.01859 (P = .0001; and 95% CI, 1.4925-3.7984). There was a significant decrease in HAPUs 1 year postimplementation.

McInnes E, Jammali-Blasi A, Bell-Syer S, Dumville J, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4):CD001735. Accessed July 10, 2014.

McGinnis E, Stubbs M. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2014;(2):CD005485. http://

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



Mercedes Tobin, MSN, RN, CBN, CMSRN, PCCN, CCRN-K, , Surgical Care Center, Vineland, NJ

Catheter-associated urinary tract infection (CAUTI) is one of the most prevalent hospital-acquired infections acquired by a patient with indwelling urinary catheters in a healthcare facility. CAUTI can impact hospital costs, extends length of stay, and impacts the quality of life of all patients afflicted by this infection. In 2012, Inspira Health Network's 2 divisions that consist of 372 beds were struggling to decrease the occurrence of CAUTIs. A cohesive interdisciplinary team led by a clinical outcomes manager was organized, and the goal was to engage clinical experts and frontline care providers in developing measures that reduced both indwelling urinary catheter utilization and the infections. A practical approach, pericare with soap and water, was implemented as an integral part of a patient daily hygiene. • Pericare with soap and water before insertion, maintenance, and every after bowel movement; • Daily review of catheter necessity; • Criteria-based insertion guidelines; • Hand hygiene and aseptic insertion technique; • Securement device to stabilize the urinary catheter tubing. H-O-R-N-O, a part of the nurse-driven protocol, is an acronym for easy memory aid and guideline utilized by staff as criteria for insertion and removal of urinary catheter with descriptions; (H) Hemodynamic instability, (O) Obstruction, (R) Retention, (N) Neurological, and (O) Other for rare exceptions like palliative care for terminally ill patients, radiation oncology patient admitted for GYN implant. An internal cost analysis that compared the inpatient stay cost of patients who developed CAUTI to the inpatient stay cost of patient with the same diagnosis who did not develop a CAUTI. The analysis mimicked national findings on the financial impact of CAUTI by showing that a direct cost rose by 88% for patients with CAUTI (approximately $10,676 per case). Outcome of this project is an 87% decrease in CAUTIs (40 counts to 5 counts).

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



Ann Roberts, BSN, RN, PCCN, , Tara Beuscher, DNP, RN-BC, GCNS-BC, ANP-BC, CWOCN, CFCN, , Melissa Parker, RN, CWOCN, , Elizabeth Longwell, BSN, RN, CWOCN, , and Julie McAuley-Gonzalez, BSN, RN, CWOCN, , Transitional Care, Charlottesville, VA

On opening 6 years ago, it quickly became apparent that this long-term acute care hospital would be a home for management of many patients with complex wound issues that accompanied their multiple other medical diagnoses. The patient population at this hospital presented a challenge that was unique. Certified wound ostomy continence nurses (CWOCNs) and the interdisciplinary team have worked to develop and implement a wound care program that provides an interdisciplinary and evidence-based approach to wound care including the training of close to 40 clinicians from the interdisciplinary team in a nationally recognized Wound Treatment Associate Program. This poster presentation traces the evolution of wound care services at this hospital through the process of active application for Disease-Specific Care Certification in Wound Care. It outlines and makes accessible to its audience The Joint Commission requirements for Disease-Specific Care Certification.

Horn J. One program's journey to Joint Commission certification for wound services. J Acute Care Phys Ther. 2012;3(3):242–245.

Isbey C, Roberts W. Disease-Specific Care Certification most cited standards: reviewers' insight [webinar]. Published October 19, 2015.

Morrison K. The road to JCAHO disease-specific care certification: a step-by-step process log. Dimens Crit Care Nurs. 2005;24(5):221–227.

The Joint Commission. Certification Review Process Guide. Oakbrook Terrace, IL: The Joint Commission; 2012.

The Joint Commission. Benefits of Joint Commission certification. http:// Published 2015.

Ostomy—Clinical Outcomes



Janet Ramundo, MSN, RN, CWOCN, CFCN, , and Jocelyn Goffney, MSN, RN, CWOCN, , Center for Professional Excellence, Houston, TX; and Mary Harris, MSN, RN, , Sugarland, TX

During 2014, approximately 150 surgeries were performed that resulted in a urinary or fecal diversion in this 918-bed quaternary teaching hospital located in a large metropolitan city. Care was provided by a team of certified WOC nurses following standards established by the WOCN Society.1–5 The complication rate for ostomy patients is reported to be as high as 63%.6 Complications result from changes in abdominal contours, parastomal hernias, and mucocutaneous separation.4 Stomal changes are also common following surgery.4 These complications can cause pouch leakage, skin damage, and odor issues. A standard of care established by the WOCN Society is a recommendation that patients with a new ostomy be provided with a comprehensive discharge plan including resources for support and assistance.1 Unfortunately, many patients did not have access to an ostomy nurse upon discharge from this hospital and elected to go to the hospital emergency department (ED) for care. These visits tied up ED staff and were costly to the patient and the hospital. An interdisciplinary group was formed to look at the needs of this patient population and consider the feasibility of providing outpatient services to ostomy patients. The team members developed criteria for outpatient visits and established services in 2014. A finding associated with clinic establishment was a reduction in ED visits for ostomy-related complications. The average cost of an ostomy-related complication was $708; the average cost for the outpatient ostomy visits was $47. In 2014, 20 patients were seen in the outpatient department, resulting in a savings of $13,220. Patients and physicians report high satisfaction with this ongoing service, and costly nonemergent ED visits are avoided.

1. 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.

2. Ostomy Guidelines Task Force; Goldberg M, Aukett LK, Carmel J, et al Management of the patient with a fecal ostomy: best practice guidelines for clinicians. J Wound Ostomy Continence Nurs. 2010;37(6):596–598.

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

4. Salvadalena G. The incidence of stoma and peristomal complications during the first 3 months after ostomy creation. J Wound Ostomy Continence Nurs. 2013;40(4):400–406

5. Salvadalena G, Hendren S, McKenna L, et al WOCN Society and ASCRS position statement on preoperative stoma site marking for patients undergoing colostomy or ileostomy surgery. J Wound Ostomy Continence Nurs. 2015;42(3):249–252.

6. Salvadalena G, Hendren S, McKenna L, et al WOCN Society and AUA position statement on preoperative stoma site marking for patients undergoing urostomy surgery. J Wound Ostomy Continence Nurs. 2015;42(3):253–256.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Valerie Kneece, BSN, RN, CWCN, , Wound Care Nursing, Quality and Patient Safety, Charleston, SC; Phill Botham, BSN, RN, ET, CWON, , Wound Care, Charleston, SC; and Danielle Scheurer, MD, MSCR, SFHM, , Quality and Patient Safety, Charleston, SC

INTRODUCTION: At an academic medical center in the Southeast, hospital-acquired pressure injury (HAPI) rates had fallen since the introduction of an education bundle in 2013. However, these numbers were still above the national average of 2.5% per the National Database of Nursing Quality Indicators (NDNQI) guidelines. A joint decision between the WOC lead coordinator and the Director of Quality & Patient Safety lead to the development of a pressure injury prevention dedicated nurse. The pressure injury preventionist (PIP) is a wound care certified nurse whose primary roles are prevention education, chart auditing, and coordinator for the hospital-wide Skin Survey Team. METHODS: The PIP began seeing all pressure injury patients to increase floor staff's familiarity with the role and assess their education needs. Chart audits were performed and sent to nurse managers for review. The PIP took an active role during NDNQI Skin Survey Days, performing random checks and being available to surveyors. RESULTS: The NDNQI Skin Survey determines the prevalence rate of HAPIs on a quarterly basis. HAPI rates were 3.4% in December 2015 and 2.7% in March 2016. After hire and training of the PIP in March 2016, survey numbers for June 2016 and September 2016 were 2.14% and 1.84%, respectively. CONCLUSIONS: A dedicated WOC nurse who focuses on pressure injury prevention alleviates the burden of prevention education on the entire WOC team. The PIP is an effective liaison between hospital administration and floor staff. With the PIP and the WOC lead coordinator, a Pressure Injury Prevention Education Bundle is planned for January 2017 to review the updated NPUAP (National Pressure Ulcer Advisory Panel) staging guidelines and a Pressure Injury Standing Order Set. The order set gives floor nurses some autonomy in their practice and improves patient outcomes by providing dressing guidelines for night shift and weekend nurses. All survey data belong to the Medical University of South Carolina (MUSC). The Pressure Injury Preventionist role at MUSC is the brainchild of Danielle Scheurer and Phillip Botham.

Wound—Preventative Practices New



Deanna Zaganas, BSN, RN, WOC, , and Dana Balassa, BSN, RN, WOC, , Glen Burnie, MD

BACKGROUND: Nurses have more injuries than any other occupation, with the majority of injuries occurring during patient handling. Recent data support that in-bed repositioning is a significant source of risk for healthcare worker injury (HCWI). These injuries are estimated to cost $22,500 each, adding $750 million in annual cost to US healthcare. Patient care standards for pressure injury (PI) prevention require acute care nurses to reposition patients in the bed as often as 6 to 10 times per shift, a significant source of HCWI risk. The goal of our project was to (1) decrease HCWI during in-bed repositioning and (2) prevent hospital-acquired sacra/buttock PI (SBPI). METHODS: We implemented a new patient positioning system (PPS) designed to (1) decrease the nursing effort required for in-bed repositioning and (2) off-load the sacrum and buttocks for PI prevention. The new practice included the use of the PPS for all patients requiring assistance with in-bed mobility. We compared outcomes before/after implementation, estimated the increase in our annual PPS spend and cost avoidance from expected decreases in HCWI/SBPI, and calculated our annual return on investment (ROI). RESULTS: Comparison of preimplementation (2015) to postimplementation (2016) found decreases in both SBPI (10.6 to 6.3 per month) and HCWI. Based on annual admissions, we expected 13 patients per day (25%) to use the PPS and found our actual use at 11 patients per day. Product spend was $677,272 and cost avoidance was $861,000, providing an annual ROI of $183,728. CONCLUSION: With the Centers for Medicare & Medicaid Services' trend toward value-based purchasing that links healthcare quality to payments, hospitals have become increasingly focused on quality. Overall quality is composed of both cost of care and realized outcomes. When cost avoidance from improved outcomes exceeds the cost of care, there is improved quality value for both patients and hospitals.

Fragala G, Boynton T, Conti MT, et al Patient-handling injuries: risk factors and risk-reduction strategies. Am Nurse Today. 2016;11(5):40–44.

US Department of Labor, Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work, 2009. http:// Published 2010.

Occupational Safety and Health Administration. Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders. Washington, DC: Occupational Safety and Health Administration; 2009.

Wound—Evidence-Based Interventions



Arturo Gonzalez, DNP, ARNP, ANP-BC, CWCN-AP, , Miami, FL

BACKGROUND: The National Pressure Ulcer Advisory Panel recommends the use of standardized measurement documentation of pressure ulcer (PU). Electronic medical record (EMR) review from a hospital indicated the lack of standardized measurement for PU by staff nurses. Student nurses undergo training to assess and evaluate PU in patients. Program includes evaluation of the wound bed, effective wound measurement, evaluation of wound edges, assessment of exudate and infection, evaluation of periwound, effective pain management, and education regarding the underlying factors that may delay wound healing. It was hypothesized that the use of this training for student nurses would enable them to provide more effective assessment and measurement of PU when compared with staff nurses currently working at the facility. METHODS: In a pilot study, 10 nurses from each group were assigned to evaluate 10 patients with PU receiving care at the facility. Both groups were required to assess the patient using the PUSH tool. Student nurses and the staff nurses were compared with assessments made by a wound care expert. RESULTS: Statistically significant differences were present in total PUSH scores for student nurses and staff nurses (P = .02). Furthermore, differences in PUSH scores provided by nursing staff and the wound care expert were noted (P = .01). However, a comparison of total PUSH scores provided by nursing students and the wound care expert indicated that there were no statistically significant differences in the scores (P = .32). CONCLUSION: Student nurse PUSH scores were commensurate with those reported by the wound care expert. Staff nurse PUSH scores were significantly different from both student nurses and the wound care expert. It seems feasible to argue that nursing students are better educated and trained to evaluate PUs in the clinical setting. As such, training provided for student nurses could provide a viable option for improving staff nurse skills for accurate assessment of PU.

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



Debbie Bartula, MSN, RN, CWON, , The Miriam Hospital, Providence, RI; and Erin Dellagrotta, BSN, RN, BC, CWON, , Education, Providence, RI

PURPOSE: Sixteen months ago, the hospital system converted to an integrated system-wide electronic health record (EHR) that presented challenges in the daily workflow of nursing staff. Chart audits revealed inaccurate pressure ulcer (PU) staging, treatment documentation not corresponding with orders, and inconsistent wound measurement. Nurses struggled with the complexity of the PU EHR components. OBJECTIVE: This quality improvement project promoted the accurate staging of PUs, initiation of nursing skin care protocols, identification of medical device–related PU risks, selecting the appropriate treatment, and comprehensive PU EHR documentation to enhance patient outcomes. PRACTICE INNOVATION: The quality improvement project included (1) policies for wound measurement guidelines and initiation of skin protocols were created; (2) medical device PU in-service presented to intensive care unit (ICU) staff and pressure ulcer prevention (PUP) team; (3) Nurse practice alerts were distributed focusing on activating the skin protocol, ensuring consistent treatment documentation, and skin workflow tips; (4) the EHR system-wide clinical informatics team sent top tips on utilization of the skin protocols and accurate PU documentation; (5) the PUP team demonstrated EHR PU documentation competency in computer lab; (6) PU housewide monthly and weekly ICU audit results were distributed to nursing administration along with action items; (7) individualized RN EHR education was provided by the ostomy/wound RNs; and (8) all ICU RNs participated in a PU Competency that reviewed staging, treatment, nutrition, respiratory device PU, and entering results into an EHR practice environment. OUTCOMES: RNs report increased confidence in EHR usage with improved PU documentation. PU Audit results have shown an increase in comprehensive PU documentation and measurement, although opportunity still exists for PU orders to coincide with documented treatment. Ongoing EHR education continues at the unit/committee level. We anticipate documentation will continue to improve as RNs continue to be more familiar with the new system.



Marilyn Germansky, BSN, MPM, RN, CWOCN, , University of Pittsburgh Medical Center, VNA, Pittsburgh, PA; Jaylynn Fisher, BSN, RN, CWOCN, , Nursing, West Mifflin, PA; and Catherine Novak, MSN, RN, CWOCN, , Nursing, Pittsburgh, PA

INTRODUCTION: Today, ostomy management is often referred to as an art and not a science. As WOC nurses, we want to further understand the concept of using stoma powder and skin protectant spray/wipes in ostomy management and the clinical indications for its use. Peristomal skin is often treated with a technique referred to as “crusting.” There is little consensus among WOC nurses as to what “crusting” encompasses as well as minimal research to address the efficacy of “crusting.” OBJECTIVES: • Identify what is considered the “crusting” technique; • Determine if WOC nurses are using “crusting” technique. METHOD: A 12-question survey was developed and reviewed by a panel of independent educators. The survey was forwarded electronically to WOC nurses who are members of the WOCN Society and nurses who are members of the CAET (Canadian Association of Electroneurophysiology Technologists) of Canada. A total of 894 responses were obtained. Raw percentages were used to analyze the data. CONCLUSION: Of the respondents, up to 50% of their time was spent providing ostomy care to both urine and fecal diversion patients. Seventy-one percent were using stoma powder and 71% used skin barrier film/spray when using stoma powder to seal in the powder. Ninety-eight percent had heard of the term “crusting.” Two techniques for performing “crusting” were identified to treat peristomal moisture-associated skin damage and medical adhesive–related skin injury. There were over a 100 variations on these 2 techniques identified. Initiation of using “crusting” was based on anecdotal experience, taught in WOC training or by their preceptor, and supplies were easy to obtain. Thirty-one percent identified it as best practice. It is clear that the majority of the WOC nurses surveyed were using the “crusting” technique and described it in the same manner. However, we ascertain that there were over 100 variations in the description that they relayed to us.

Thomas ME. The providers' coordination of care: a model for collaboration across the continuum of care. Prof Case Manag. 2008;13(4):220–227.

Seungmi P, Yun Jin L, Doo Nam O, Jiyun K. Comparison of standardized peristomal skin care an crusting technique in prevention of peristomal skin problems in ostomy patients. J Kor Acad Nurs. 2011;41(6):814–850.

Morgan N. Understanding the crusting procedure. Wound Care Advis. 2014;3(3):23–24.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Sherry Tennies, MSN, RN, CWOCN, , Inpatient Wound Ostomy, West Bend, WI

INTRODUCTION: Skin safety is dependent on early identification of pressure ulcer risk and implementation of targeted, evidence-based interventions to mitigate risk. Lack of consistent implementation of preventative skin interventions at a Midwestern community hospital was identified as a factor in low, but constant, hospital-acquired pressure injury/ulcer (HAPU) rates. With a goal of zero HAPUs, a preventative program was implemented that included a skin inspection performed by 2 staff, which was termed “Four Eyes,” and a Pressure Ulcer Prevention (PUP) Best Practice Bundle. The PUP Bundle lists evidence-based, targeted interventions for Braden subscale scores less than or equal to 2. The interventions address 4 risk categories: sensory, mobility, and activity; moisture; friction and shear; and nutrition. METHODS: The Plan-Do-Study-Check framework guided the practice changes. Skin inspection documentation and a link to the PUP Bundle were incorporated into the electronic medical record (EMR). All nursing staff were educated via a computer-based learning module in May 2016. The skin inspection and PUP Bundle went live on July 1, 2016. Lag measures are pressure injury incidence and completion of skin inspection. Lead measures are skin care interventions. RESULTS: For third-quarter 2016, HAPU rates initially increased on the intensive care unit and medical-surgical units by 4.67 and 11.11 HAPUs per 1000 patient-days, respectively. Just-in-time education was conducted with staff by the WOC nurse throughout the third quarter, emphasizing the PUP Bundle interventions. By the end of October 2016, all units achieved zero HAPUs. CONCLUSION: Education improves skin assessment skills, which may lead to an initial increase in pressure injury rates due to increased awareness. A tool with bundled, targeted, evidence-based skin care interventions can effectively prevent HAPUs and improve patient safety.

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

Centers for Disease Control and Prevention. Catheter-associated urinary tract infection (CAUTI) event: guidelines and procedures for monitoring CAUTI. http:// Accessed May 18, 2016.

Minnesota Hospital Association. Roadmap to a Comprehensive Skin Safety Program. http:// Published January 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.

Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality; 2011. http://

Wound—Evidence-Based Interventions



Molykutty Lukose, MSN, CWON, CFCN, , and Dorothy Jones, BSN, RN, CWCN, , Clinical Practice Office, Houston, TX; Lillykutty Thomas, MSN, RN, , Clinical Practice Office, Houston, TX; Gustavo Camacho-DelRio, MBA/MHA, MAP, BSN, RN, , Michael E. DeBakey VA Medical Center, Houston, TX; Jacquelyn Sharkey, BSN, MBA/HCM, RN, , Clinical Practice, Houston, TX; and Ruby Chu, RN, CCRN, , Education Care Line, Houston, TX

BACKGROUND: Medical device–related pressure injuries secondary to the use of devices applied for diagnostic or therapeutic purposes are a significant problem in health care facilities. Skin Risk Management team at a large teaching facility in South Central United States implemented a prevention program to reduce the hospital-acquired pressure ulcer (HAPU) from nasal cannulas. The incidence of nasal cannula–related HAPUs was 5.4% starting January 2014 to November 2014. AIMS: To evaluate if the use of soft silicone nasal cannula device would reduce the hospital-acquired pressure ulcer in adult patients. METHODS: Utilizing the PDCA (Plan-Do-Check-Act) cycle, an action plan was initiated. A multidisciplinary team assessed the current state of practice (hard nasal cannula/high-flow padded with foam dressing to protect the posterior ear to prevent skin breakdown) and investigated the cause of HAPU from the nasal cannula. Literature review was conducted for best practice and other alternative for nasal cannula. The soft silicone nasal cannula was piloted for 2 weeks in July 2014 and then implemented throughout all nursing units. Staff education was provided on proper device application, skin assessment, and documentation. Evaluation tool was created for pre- and postassessments. Follow-up teachings were organized for compliance. RESULTS: Incidence of nasal cannula–related HAPUs decreased to zero and maintained for 23 months after soft silicone nasal cannula implementation. The potential yearly cost saving was $41,932 from eliminating the use of foam padding in addition to nursing time gained. CONCLUSION: A collaborative effort using the PDCA framework achieved an HAPU rate of zero. Use of soft silicone nasal cannula and staff education were instrumental in HAPU prevention. The medical Center implemented soft nasal cannula and posterior ear check as a standard of care.

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(5)358–365.

Norman J. MDR pressure ulcers: who thought plastic tubing could be harmful? Healthy Skin. Published 2013.

National Pressure Ulcer Advisory Panel. NPUAP pressure injury stages. http:// Published 2016.

Continence—Issues in Bladder and Bowel Continence Management



Cecilia Zamarripa, MSN, RN, CWON, , Department of Enterostomal Therapy Nursing, Pittsburgh, PA; Carol Mathews, BSN, RN, CWOCN, , University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, PA; Lisa Donahue, DNP, RN, CPPS, , Patient Safety and Innovation, Pittsburgh, PA; Kristian Feterik, MD, , General Internal Medicine, Pittsburgh, PA; Sarah Cua, MSN, MBA, RN, , Transplant Intensive Care Unit, Pittsburgh, PA; and Janet Mullen, BSN, BA, RN, CWOCN, CFCN, , University of Pittsburgh Medical Center Passavant Hospital, Pittsburgh, PA

The use of nasopharyngeal airway devices as off-label rectal trumpets to manage fecal incontinence resulted in several serious events that compromised safe patient care. Best approaches for fecal containment and skin integrity management were reviewed and revised to improve patient safety and to provide staff with safe alternatives for fecal management. Previous policy and guidelines regarding the use of all fecal containment devices were revised to reflect the changes made to promote best patient care outcomes and safe use. This process resulted in removing nasopharyngeal airway as off-label rectal trumpet use. A Fecal Containment Management Order set was developed to ensure a safe patient selection and use of an optional fecal containment device. Serious events related to bleeding associated with rectal trumpet use were noted, and data collected revealed additional fecal management issues such as laxative and stool softener usage regardless of liquid stool presence. Fecal containment management policy revision, nursing and medical staff reeducation, and development of a proactive diarrhea management bundle for patients with device contraindications were addressed and developed. The alternative fecal management system listed several precautions and contraindications to the product use. Additional process changes when device is ordered include automatic WOC nurse consult to assess the patient and conduct a review of the electronic health record. After the initial assessment, and if the fecal containment device is contraindicated for use, the WOC nurse completes the form that lists the potential contraindications. If contraindications, the WOC nurse will not release the fecal containment device and the order set is discontinued. The provider may choose to override this order for the best interest of the patient, but if that choice is made, the provider will be required to obtain consent from the patient/family detailing the potential risk and benefit of using the device.

Clinical Evaluation of a Flexible Fecal Incontinence Management System. Phase II Clinical Results. Data on File. ConvaTec; 2004.

Flexi-Seal FMS [product insert]. Instructions for use. ConvaTec; 2012.

Howe K, Padmanabhan A, Stern MA, et al Managing diarrhea and fecal incontinence: results of a prospective clinical study in the ICU. J Wound Ostomy and Continence Nurs. 2005. Abstract 638.

Padmanabhan A, Stern M, Wishin J, Mangino M, Richey K, DeSane M. Clinical evaluation of a flexible fecal incontinence management system. Am J Crit Care. 2007;16:384–393.

Wishin J, Gallagher TJ, McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):104–110.

Wound—Preventative Practices New



Jennifer OBrien, BSN, RN, CWOCN, CFCN, , Chapel Hill, NC; Krystyna Dixon, MSN, RN, CWOCN, CFCN, , Duke Raleigh Hospital, Raleigh, NC; and Tracy Carroll, MSN, RN, NE-BC, CMSRN, , Heart and Vascular Services, Chapel Hill, NC

In the acute care setting, the bedside nurse's comfort level with foot care is generally limited to routine skin care and personal hygiene. Foot and nail assessment, clinically appropriate care, and patient education are essential for improving foot health and preventing complications. For decades, hospitals have been unable to provide foot and nail care due to numerous challenges including limited resources and specialists and a lack of formal programming. This was recognized at our academic medical center, and a taskforce, comprised of a certified foot care nurse (CFCN) and the unit manager, was formed to initiate an Advanced Foot Care Program as part of the WOC nurse consult service for hospitalized patients. The first phase of the program development was a partnership with a fellow CFCN at another local academic medical center. By working together and sharing ideas, both CFCNs were able to develop specialized foot care programs at their respective institutions. The second phase was policy writing and approval, equipment procurement, and determination of a sterilization process. An order set for “CFCN consult” was added to the electronic medical record. Staff awareness of the Advanced Foot Care Program was promoted through presentations, e-mail notifications, rounding, and unit postings. The third phase involved providing care to patients needing foot care. Additional consults were obtained as bedside staff became more familiar with the resources available and the benefits of foot care. In 7 months, more than 90 patients received advanced foot care in the 2 organizations. Feedback from staff has been very positive, and promotion of the programs continues. Patient satisfaction has been the most rewarding aspect, and there has been confirmation for this much-needed advanced service. The WOC nurses at each entity continue to work together to make program enhancements and share best practices related to foot care.

Aalaa M, Tabatabaei Malazy O, Sanjari M, Peimani M, Mohajeri-Tehrani MR. Nurses' role in diabetic foot prevention and care; a review. J Diabetes Metab Disord. 2012;11:24.

Chan HYL, Lee DTF, Leung EMF, et al The effects of a foot and toenail care protocol for older adults. Geriatr Nurs. 2011;38:446–453.

Gallagher D. The certified foot care nurse and the importance of comprehensive foot assessments. J Wound Ostomy Continence Nurs. 2012;39:194–196.

Wound, Ostomy and Continence Nurses Society. Best Practice Guidelines Management of Wounds in Patients With Lower-Extremity Arterial Disease. Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2014.

Wound, Ostomy and Continence Nurses Society. Best Practice Guidelines Management of Wounds in Patients With Lower-Extremity Neuropathic Disease. Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2012:100.

Ostomy—Clinical Outcomes



Christine Dorman, MS, ANP-C, RN, CWOCN, , and Kaci Costello, BSN, RN, CWOCN, , Out-Patient, New York, NY; and Tracey Liucci, BSN, RN, COCN, , and Elizabeth Larson, BSN, RN, COCN, CCCN, , Wound Care Team, New York, NY

PURPOSE: To establish the role of the WOC nurse in the management of wet colostomies in gynecological cancer patients, identifying the needs of patients and health care personnel, and identify complications specific to living with a wet colostomy. Wet colostomies have gained resurgence for the surgical treatment of locally advanced gynecological cancers, thrusting the WOC nurse into unfamiliar territory. Historically, a wet colostomy was performed by implanting ureters into the distal sigmoid colon, but data showed that patients experienced metabolic abnormalities, increased risk of urinary tract infections (UTIs) and kidney damage, along with an increased risk of postoperative complications. The surgical procedure has been modified to implant the ureters into the distal limb of the sigmoid loop colostomy, which functions as a conduit for urine, while the proximal lumen allows for flow of feces. The patient has 1-stoma versus the traditional 2-stoma approach. OBJECTIVE: Sparse information is available in the literature about “standard of care practices” for WOC nurses' management of wet colostomies. No established teaching tools are available specific to wet colostomies for patients and health care personnel (hospital and home care based). No data are available for the incidence of recidivism secondary to long-term complications of wet colostomy surgery (eg, kidney damage, UTIs, metabolic abnormalities). OUTCOMES: Educated GYN surgeons and medical staff regarding standard of care for consulting the certified WOC nurse preoperatively and postoperatively for wet colostomy patients. Developed patient educational material for the management of a wet colostomy. Initiated appropriate referrals to social work, psychiatry, visiting nurse, and sexual rehabilitation. WOC nursing needs to research topic.

Backes FJ, Tierney BJ, Eisenhauer EL, Bahnson RR, Cohn DE, Fowler FM. Complications after double-barreled wet colostomy compared to separate urinary and fecal diversion during pelvic exenteration: time to change back? Gynecol Oncol. 2013;128(1):60–64.

Guimaraes GC, Ferreira FO, Rossi BM, et al Double-barreled wet colostomy is a safe option for simultaneous urinary and fecal diversion. Analysis of 56 procedures from a single institution. J Surg Oncol. 2006;93(3):201–211.

Kecmanovic DM, Pavlov MJ, Ceranic MS, Masulovic DM, Popov IP, Micev MT. Double-barreled wet colostomy: urinary and fecal diversion. J Urol. 2008;180(1):201–204.

Pierce M, Rice M, Fellows J. Wet colostomy and peristomal skin breakdown. J Wound Ostomy Continence Nurs. 2006;33(5):541–543.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Melanie Hardy, BSN, RN, CWOCN, , Denton, TX

BACKGROUND: In December 2009, our acute care hospital implemented a comprehensive Pressure Injury Prevention Program, titled the “Happy Hiney Program,” after identifying 101 HAC (hospital-aquired condition) pressure injuries. Focus was on changing the staff misconception that HAC pressure injuries were the WOC nurse's responsibility, and the importance of maintaining skin integrity based on HAC pressure injuries being viewed as an indicator of quality, the associated financial impact, and risk of litigation. Nursing Administration supported the formation of RN-driven protocols to reduce HAC pressure injuries based on evidence-based research (SOE = A) from the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel that focused on combating the 4 extrinsic factors that contribute to HAC pressure injuries: • shearing; • pressure; • friction; and • microclimate. METHODS: (1) Identify at-risk patients with a Braden Scale score of 18 or less, reassess every shift and document findings. (2) Implement “Happy Hiney Program” hospital-wide, on admission by: •Applying silicone 5-layer dressing to sacrum, label with “smiley faces” for prevention (no skin breakdown) or “sad faces” (impaired skin). • Use of a static air overlay mattress for pressure redistribution. (3) Licensed staff completed the NDNQI pressure ulcer (PU) tutorial for 1.5 CEUs. (4) Developed Wound Care Council (WCC) chaired by the WOC nurse, composed of Skin Champions from units who meet monthly for prevention of HAC pressure injuries, review products and protocols, and complete quarterly prevalence studies. (5) Developed wound care protocols linked with product photos located in supply rooms for reference; products bins were color coded. (6) Mandatory Skills Fair for staff on pressure injury staging and documentation; correct product use. CONCLUSION: December 2009 = 101 HAC PU rate; December 2010 = 59 HAC PU rate; December 2011 = 23 HAC PU; December 2012 = 23 HAC PU; December 2013 = 10 HAC PU; December 2014 = 16 HAC PU; December 2015 = 9 HAC PU. These findings show that over 80% sustained reduction in HAC pressure injuries and prompted support of the prevention program and greatly reduced cost of HAC pressure injuries and bed rentals. The protocols were critical in our achievement of our Magnet designation, and the results have been replicated by other facilities.

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



Jan Kass, RN, CWON, [email protected], Wound Healing Service, Coronado, CA

BACKGROUND: This study took place in a 210-bed community hospital, with a 64-bed long-term acute care (LTAC) unit that serves chronic critically ill patients. Common diagnoses include amyotrophic lateral sclerosis, multiple sclerosis, traumatic brain injury, muscular dystrophy, quadriplegia, and stroke. Patients are predominantly immobile, ventilator-dependent or assisted. Patients require side-to-side repositioning and boosting in bed, placing staff at risk of musculoskeletal disorders (MSDs). The average cost of modified duty for a staff injury is estimated at $15,600.00 (OSHA, 2011). PROBLEM: Eleven states including California are mandated to implement Safe Patient Handling Mobility (SPHM), including technology to aid in the movement, transfer, and positioning of patients. In 2014, 9 injuries in our LTAC were related to patient positioning. Lack of a standardized turning and repositioning system posed a challenge. OBJECTIVE: Reduce caregiver injury using a Nonpowered Reactive Support Surface Position System (NRSSPS). Positive air displacement and nylon fabric decrease pressure, friction, and shear. The system includes a fluidized positioner. Long handles for turning promote proper ergonomics. METHOD: Over 1 year, 60 patients aged 20 to 60 years who met inclusion criteria were placed on the NRSSPS. Staff were instructed in correct use of the NRSSPS. Injury rates were compared to those of the prior year. RESULTS: Reported MSD patient positioning injuries decreased from 9 in 2014 to 1 in 2015, realizing a savings of $108,848.00. CONCLUSION: The use of the NRSSPS as part of a comprehensive SPHM program contributed to the reduction of staff injury. Further research is needed to determine the effects of using an NRSSPS to offload boney prominences and decrease hospital-acquired pressure injury.

American Nurses Association. Safe patient handling and mobility. http:// Published 2013.

Borden CM, ed. Patient movement and handling assessments: a white paper. The Facilities Guidelines Institute Web site. http:// Published 2010.

US Department of Labor, Bureau of Labor Statistics. News release USDL 15-2205. Published November 9, 2015.

Wound—Preventative Practices New



Margaret Hiler, MSN, RN, CWOCN, , Nursing Administration, Washington, DC; Dot Goodman, BSN, RN, CWOCN, , Gerogetown University Hospital, Washington, DC; Ashna Saxena, MHA, , Utilization-Quality Improvement, Washington, DC; and Jenna Riley, BSN, RN, CCRN, , Washington, DC

PROBLEM: Development of pressure injuries underneath medical devices is becoming increasingly prevalent in critically ill patients.1 In one acute care academic medical center in the mid-Atlantic region, 40% to 45% of all pressure injuries are related to medical devices. Many pressure injuries develop underneath the faceplate of tracheostomy tubes in patients in an intensive care unit (ICU) who underwent an emergent or bedside tracheostomy. Nurses attribute injuries to lack of pressure-relieving dressing usage. Dressing usage is often limited by tight suturing and unclear communication between nurses and pulmonary physicians, resulting in delayed suture removal. OBJECTIVES: To decrease trach-related pressure injuries (TRPIs) by: • identifying a dressing that effectively reduces pressure, moisture, and contact between skin and trach faceplate; • improving communication between physicians and nurses. METHODS: A group of key ICU stakeholders including nursing, physicians, and a WOC nurse convened and identified areas for improvement: (1) the available moisture-wicking dressing was disliked by physicians and therefore not being used; (2) standardization of trach care in this population. OUTCOMES: • The WOC nurse acquired samples of several products. Physicians and nurses identified a highly absorbent polyurethane tracheostomy dressing as the preference for use at time of insertion and for continued care. • A clinical nurse III developed a communication form to be placed at patient's head of bed to display pertinent care protocols and lines of communication. RESULTS: In the fiscal year (FY) 2015, there were 8 TRPIs. There were also 8 TRPIs within the first 2 quarters of FY2016. Upon implementation of the aforementioned interventions, there was 1 TRPI in quarter 1 (Q1) and zero in quarter 2 of FY2016. There was 1 TRPI in Q1 of FY2017. Audits of use of bedside communication tool showed 100% compliance.

1. NDNQI. Pressure ulcer training v. 5.0. Published 2016. Accessed November 1, 2016.

Wound—Management of Complex Wounds



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

Pyoderma gangrenosum (PG) occurs in 1 in 100,000 patients annually nationwide. Standard treatment includes autolytic debridement, exudate management, protection from trauma, and steroid therapy. Here, we present management of a case of PG that developed postoperatively after abdominoperineal resection (APR) for rectal adenocarcinoma. Perineal dehiscence was noted prior to abdominal ulceration development. Due to unknown etiology, uncontrolled pain, and degree of wound necrosis dressing, initial management and care were carried out under anesthesia in the operating room, utilizing advanced wound care products such as antimicrobial foams, alginates, and negative pressure wound therapy (NPWT) foam. Upon suspicion of PG, all sharp debridement was discontinued. Baseline abdominal ulcer measurements were 8 × 13 × 0.3 cm. Full-thickness ulceration completely encompassed the peristomal plane, not allowing for standard application of an ostomy wafer and pouch, which significantly increased the level of complexity. Use of an antimicrobial silicone contact layer on the abdominal wound bed was paramount in addressing the needs of this patient. Goals of care focused on protecting the wound bed from trauma, pain reduction, exudate control, reduction in the level of bioburden within the wound bed, and support autolytic debridement, all while trying to maintain a seal around the stoma to reduce contamination of effluent into the wound bed and ensure sufficient pouch wear time. We maintained a seal on the abdominal wound and around the stoma to allow for a 7-day wear time. Upon discharge from the hospital, the patient returned weekly for dressing change in the outpatient office by the WOC nurse. The abdominal wound was fully epithelialized and healed within 13 weeks. No systemic signs of infection were noted throughout entire course of treatment. The perineal wound was fully epithelialized 51 weeks after initial APR.

Aggarwal S. Recognition and management of pyoderma gangrenosum. Prim Health Care. 2012;22(5):26–30.

Baglieri F, Scuderi G. Therapeutic hotline: infliximab for treatment of resistant pyoderma gangrenosum associated with ulcerative colitis and psoriasis. A case report. Dermatol Ther. 2010;23(5):541–543.

Fraccalvieri M, Fierro M T, Salomone M, et al Gauze-based negative pressure wound therapy: a valid method to manage pyoderma gangrenosum. Int Wound J. 2014;11(2):164–168.

Zuo KJ, Fung E, Tredget EE, Lin AN. A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. J Plast Reconstr Aesthet Surg. 2015;68(3):295–303.

Wound—Preventative Practices New



Rita Whitney, CWOCN, , Wound/Ostomy, Lewisville, TX

BACKGROUND: In the 8-bed intensive care unit (ICU) at the Medical Center of Lewisville, hospital-acquired pressure ulcers (HAPUs) are lower than benchmarks but were still occurring at higher rate than other units. CLINICAL QUESTION/PRACTICE PROBLEM/TYPE OF STUDY: This was a performance/quality improvement project. PICO question: In ICU patients, does the use of a sacral foam dressing decrease the number of HAPUs on the sacrum? METHODS: The problem was identified through quarterly pressure ulcer prevalence surveys and ongoing surveillance of data. We worked with Critical Care PPC and instituted a new intervention of applying silicone sacral dressing to all ICU patients in the 8-bed general ICU. Data were collected using a retrospective review. RESULTS: In the 2-year period prior to intervention, the ICU had HAPUs on the sacrococcyx as follows: 11 deep tissue injuries (DTIs), and 5 stage II HAPUs. In the 2-year period following the intervention, the ICU has had HAPUs on the sacrococcyx: 5 DTIs, and 4 stage II HAPUs. This showed more than a 50% improvement in the number of DTIs to the sacrococcyx, as well as a reduction in the number of stage II HAPUs. CONCLUSIONS/IMPLICATIONS: Although not a controlled study, the results were significant. Since no other new interventions were implemented during this time period (no change in support surfaces, skin care products, incontinence pads, repositioning protocols, etc), we concluded that the prophylactic use of a soft silicone-bordered sacral foam dressing decreased sacral HAPUs in the ICU. LESSONS LEARNED/RECOMMENDATIONS: In view of the positive results and nursing staff feedback, we have extended the use of prophylactic sacral foam dressings to high-risk patients on all inpatient adult nursing units.

Brindle C. Identifying high-risk ICU patients: use of an absorbent soft silicone self-adherent bordered foam dressing to decrease pressure ulcers in the surgical trauma ICU patient. J Wound Ostomy Continence Nurs. 2009;36(3):S27.

Brindle C. Outliers to the Braden Scale: identifying high-risk ICU patients and the results of prophylactic dressing use. WCET J. 2010;30(1):11–18.

Kalowes P, Carlson C, Lukaszka D, Sia-McGee L. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Paper presented at: SAWC Fall; September 12-14, 2012; Baltimore, MD.

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. 2015;12(3):302–308. doi:10.1111/iwj.12101.

VanWyhe J, Willer S, Blackley M, Slevin A, Johnson P. Use of an absorbent soft silicone self-adherent bordered foam dressing to decrease incidence of sacral pressure ulcers in the ICU. J Wound Ostomy Continence Nurs. 2012;39(3):S68.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Charlotte Allen, MSN, RN-BC, CWOCN, , Nancy Ochs, MSN, RN, CWON, CFCN, , and Donalyn Alexander, DNP, RN-BC, CLNC, , Department of Education and Professional Development, Abilene, TX; and Treva Broderick, PT, , Rehabilitation Services, Abilene, TX

BACKGROUND: Pressure injuries continue to be a major health condition in hospitalized patients. In the United States, it is estimated that 3 million adults are affected. In acute care hospitals, the estimated range of prevalence is between 0.4% and 38%. Between 1990 and 2001, pressure injuries were a cause of death in almost 115,000 people. The annual spend on pressure injuries in the United States is $11 billion, with the average cost of treatment between $37,800 and $70,000 per injury (Qaseem, Mir, Starkey, Denberg, & Clinical Guidelines Committee of the American College of Physicians, 2015). As of 2008, hospital-acquired pressure injuries were placed on the Centers for Medicare & Medicaid Services list of preventable hospital-acquired conditions (HACs), also known as “never events,” causing hospitals to now absorb the extra cost for pressure injury treatment (Centers for Medicaid & Medicare Services, 2008). PROCESS: Despite various intensive prevention strategies by the nursing staff, hospital-acquired pressure injuries continued to challenge a 350-bed, acute care nonteaching regional hospital in the Southwestern United States. Realizing that pressure injury prevention is a facility-wide responsibility, an interprofessional task force was developed. The departments represented included medical/surgical units, critical care unit, radiology, perioperative services, physical therapy, transport services, cardiac catheterization lab, respiratory services, trauma/emergency services, clinical informatics, nursing administration, education, infection prevention, dietary, and environmental services. Research was conducted on current evidence-based prevention strategies, and many hospital-wide initiatives were implemented. Specialty areas also developed and executed unit-specific action plans. This committed team worked collaboratively to implement changes in products, practice, documentation, communication, and education. These new practice strategies resulted in positive changes in patient outcomes as evidenced by a reduction in hospital-acquired pressure injuries. OUTCOMES: The acute care hospital-acquired prevalence benchmark is 5% (J. Black, personal communication, June 5, 2015). Through the efforts of this interprofessional task force and the bedside nursing staff, the hospital has seen a reduction in hospital-acquired pressure injuries from 8.29% to 3%.

Centers for Medicaid & Medicare Services. Fact sheets: CMS improves patient safety for Medicare and Medicaid by addressing never events.

Qaseem A, Mir T, Starkey M, Denberg T; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):359–369.

Wound—Preventative Practices New



Zoe Carter Bishop, BSN, RN, CWOCN, , Inpatient Wound Care, Des Moines, IA

The project's purpose was to improve the outcomes of posttracheostomy (trach) care of inpatients. The problem identified was the increasing hospital-acquired pressure ulcer (HAPU) injuries related to the postcare of this tracheostomy population. The objectives included: • Change the mind-set from reactive intervention to team prevention based on 6 evidence-based references (available upon request) and best practice data. Key elements included identification of key members and providers of the multidisciplinary team and secure their engagement and commitment to the project. • Reduce variation in practice with standardized postinsertion management with minimal complications and improvement of outcomes with predictable and measurable positive results. Development of a round table work group facilitated discussion of evidence-based data to minimize and eliminate exposed anecdotal variations in practice. • Improve commitment of bedside staff, patients, and families by reducing fragmentation of care, elimination of anecdotal practices, and implementation of cost-effective balanced outcomes with improved delivery of care. In summary, a change to a prevention focus improved standardization of care with predictable outcomes and reduced pressure injuries related to posttrach care. Data from a baseline 24-month period identified 252 tracheostomies (ICD-9 codes 31.1 and 31.29) performed. Sixteen percent (n = 14) of device-related pressure ulcers were related to tracheostomies. Those reported injuries were stage II, III, and suspected deep tissue injuries (DTIs) and unstageable pressure injuries. Since implementation of these strategies, 1 device-related pressure ulcer (N = 207 total trach procedures) occurred in the 20 months following implementation of prevention strategies since January 2015. Nursing care protocols and value-added dressing products were updated. Provider standard orders were developed to include an evidence-based standard of care available through the electronic medical record.

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



Jesse Robles, BSN, RN, CCRN, , Critical Care-ICU/DOU, San Diego, CA; and Heather Bivens, MSN, RN, ACNS-BC, , Critical Care-DOU, San Diego, CA

PURPOSE: Patients admitted to critical care units (CCUs) in hospitals are more susceptible to developing hospital-acquired pressure injuries (HAPIs). Despite advances in specialty beds, mattresses, and prevention bundles, patients are still developing HAPIs in CCUs due to their severe illness and comorbidities. A key part of pressure injury prevention is repositioning; however, off-loading pressure areas is difficult to assess without a diagnostic tool. Additionally, studies have shown that current repositioning practices fail to off-load areas completely, which may contribute to HAPIs. Evidence confirms the effectiveness of using a real-time pressure monitor (RTPM) to off-load high pressure areas effectively, serving as a visual guide to decrease skin interface pressures with assurance. METHODS: RTPMs were placed on existing mattresses in the intensive care unit/direct observation unit. Healthcare providers (HCPs) utilized the RTPMs to manage interface pressures. A historical comparison group of the same units had only the pressure ulcer prevention bundle with the mattress. RESULTS: RTPMs identified mattresses that were not being used in therapeutic mode, hence not to maximum benefit. Many mattresses were exposing patients to very high pressures. HCPs adjusted modes on the mattresses to provide therapeutic pressure redistribution. HCPs were also able to adjust the air in the mattresses to find better pressure redistribution for individual patients. Peak pressures were identified, and interventions were taken to lower these high pressures with assurance using the RTPM color image. The RTPM group developed 2 HAPIs over 3 months, whereas 5 developed when the RTPM was not used. CONCLUSION: RTPMs provided visual assessment and monitoring of interface pressures, allowing HCPs to maximize the use of existing mattresses and reposition patients with enhanced pressure redistributions. RTPMs assured existing mattresses were being utilized to maximum therapeutic benefit. HAPIs decreased with the use of the RTPM.

Peterson MJ, Gravenstein N, Schwab WK, Van Oostrom JH, Caruso LJ Patient repositioning and pressure ulcer risk-Monitoring interface pressures of at-risk patients. J Rehabil Res Dev. 2013;50(4):477–488. doi:10.1682/JRRD.2012.03.0040.

Russo AC, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. HCUP Statistical Brief No. 64. Published 2008. Accessed January 18, 201.

Swafford K, Culpepper R, Dunn C. Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. Am J Crit Care. 2016;25(2):152–155. doi:10.4037/ajcc2016963.

Behrendt R, Ghaznavi AM, Mahan M, Craft S, Siddiqui A. Continuous bedside pressure mapping and rates of hospital-associated pressure ulcers in a medical intensive care unit. Am J Crit Care. 2014;23(2):127–133.

Ostomy—Psychosocial and Quality-of-Life Aspects



Nicolien Wilder, RN, CRRN, WCC, CFCN, , Nursing, Charlottesville, VA

Fifty-three-year-old female, Sarah (not her real name), status post–sigmoidectomy with end ileostomy. History of Guillain-Barré syndrome at the age of 18 years, functioning at wheelchair level since then. Contractures in both hands, no fine motor control. To go home, she needed to be able to empty her high-output ileostomy bag on her own. Sarah, the occupational therapist, and the nurse problem solved together. To simplify the process, we chose to use the closed, 2-piece disposable ostomy bags. With the barrier in place, Sarah had to have the ability to do 2 things: (1) pull the bag off and (2) snap a new bag on. The occupational therapist noticed the belt loops on the ostomy bag. She created a hook on a stick that Sarah could hold between her palms. Now Sarah could place this hook through a belt loop and pull the full bag off and place it into a readied garbage bag. Sarah could not snap a new bag to the barrier. Pushing down on this was ineffective and painful to her stomach. She could not place her fingers under the floating ring for support. The nurse searched for a support that could slide under the floating ring. She chose a thin plastic ostomy education template. The plastic stoma was cut away from the template, a little bigger than the size of the ring on the barrier, so that it would slide effortlessly under the ring. This now gave the necessary support so that Sarah could indeed push down on the bag and her stomach. She now could snap the bag in place on the barrier. Sarah was now able to go home as she had wished and manage most of her ostomy care. Sarah dubbed the device her “six-pack abs.”

Ostomy—Product Selection and Innovations



Elisabeth Hardy, RN, CWON, , Wound Ostomy, Portland, OR

A 9-year-old girl sustained multiple injuries while a restrained passenger in a motor vehicle accident in which her mother and identical twin sister perished. Initial diagnoses included abdominal aortic dissection at the renal artery, multiple intestinal perforations, subarachnoid hemorrhage, pulmonary and myocardial contusions, and other injuries. During the first 6 weeks of hospitalization, she had 23 visits to the operating room for washouts, bowel decompressions, resections of necrotic bowel, and intestinal repairs. Ultimately, the abdominal wound was treated with split-thickness skin graft around multiple fistulae. PROBLEM: After close to a year of hospitalization, she was ready for discharge in every aspect, save for the need for continuous suction to maintain the integrity of the fistula pouch. Portable suction machine was effective but much too loud to live with on a constant basis. CLINICAL APPROACH: The hospital purchased a negative pressure wound therapy machine to send home with her. The diameter of the machine's canister tubing was too small to accommodate the fistula effluent, thereby compromising the function of the suction. The WOC team attached a standard suction canister to the machine's canister so that the effluent was collected into the standard suction canister. This system provided silent continuous suction. OUTCOME: The patient was discharged home with her fistula pouch intact and connected to suction. She came to us daily for pouch changes, but she was able to attend public school, resuming a more normal routine. She adapted to carrying the machine and canister with her. CONCLUSIONS: Partnering with the discharge team of the children's hospital and the vendor, the WOC team helped achieve a sustainable discharge plan. Her fistula has since been closed, and she remains on total parenteral nutrition until her intestinal tract is surgically put back into continuity

Wound—Preventative Practices New



Rebecca Rothemich, BSN, RN, CWON, CFCN, , Wound Care, Charleston, SC

Foot ulceration is a common and significant complication of diabetes mellitus. Yearly incidence is currently estimated to be 2%, with lifetime incidence of 15% to 25% and recurrence rate of 30% to 40%. Etiology is typically multifactorial and places stress on the patient, healthcare systems, and society as a whole. It is reported that only two-thirds of foot ulcers will eventually heal and that up to 28% may result in some form of lower extremity amputation (Bus et al, 2015). Prevention of ulceration is of utmost importance in reducing physical and financial burdens on the patient and healthcare. At an academic, Magnet-designated medical center in the Southeastern United States, there is currently no formal standard operating procedure (SOP) by which certified foot care nurses may practice. A review of the literature revealed insufficient evidence to support interventions in the prevention of a first foot ulcer. One systematic review reports some evidence to support interventions in the prevention of recurrent foot ulcers, with recommendations made. The recommendations were appraised using the University of Pennsylvania's Center for Evidence-Based Practice Trustworthy Guideline rating scale and found to be trustworthy. An evidence-based practice summary was compiled, leading to a strong recommendation with low quality of evidence. As a result of the evidence review, an SOP is in development that will incorporate foot care guidelines as defined by the state nursing board, as well as the recommendations made in the systematic review. Implementation of this SOP will provide optimal foot care to this at-risk population and will increase opportunities to add to the current evidence.

Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ; International Working Group on the Diabetic Foot. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes Metab Res Rev. 2016;32(suppl 1):2–6. doi:10.1002/dmrr.2694.

Bus SA, van Netten JJ, Lavery LA, et al; on behalf of the International Working Group on the Diabetic Foot. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Published 2015. Accessed May 10, 2016.

Hoogeveen RC, Dorresteijn JA, Kriegsman DM, Valk GD. Complex interventions for preventing diabetic foot ulceration. Cochrane Database Syst Rev. 2015;8:CD007610. doi:10.1002/14651858.CD007610.pub3.

VanNetten JJ, Price PE, Lavery LA, et al Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32(suppl 1):84–98.

Ostomy—Product Selection and Innovations



Jessica Lieder, MSN, APRN, ANP-BC, IIWCC-NYU, , Elizabeth Savage, MSN, APRN, ACNS-BC, CWON, , and Sarah Lebovits, MSN, RN, ANP-BC, CWOCN, DAPWCA, IIWCC-NYU, , Wound & Ostomy Program, New York, NY

PURPOSE/OBJECTIVE: At a large Magnet academic medical center in Metropolitan New York City, the Wound & Ostomy Program noted frequent postoperative conversion to convexity within the first month, with a large volume of visits to the clinic. Patients were experiencing leakage and/or poor appliance wear time and resultant peristomal chemical irritant dermatitis necessitating a conversion to convexity. The Wound & Ostomy Program advanced practice nurses (APNs) sought a solution. A review of the literature showed limited evidence for the routine use of convexity postoperatively to reduce postoperative pouch changes as well as leakage. The APNs decided to trial using soft convexity as the standard of care versus flat pouching systems for postoperative ostomy patients as long as not contraindicated (eg, patient preference, product availability) to decrease outpatient clinic visits and postoperative pouch changes to convexity. OUTCOMES: After conversion to soft convexity rather than a flat pouch as the standard of care initially postoperatively, a significant decrease in postoperative visits to the outpatient clinic for peristomal chemical irritant dermatitis in the setting of leakage and poor appliance wear time was noted. A decrease in patient-reported dissatisfaction with postoperative management as a secondary outcome was identified.

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

Kruse TM, Storling ZM. Considering the benefits of a new stoma appliance: a clinical trial. Br J Nurs. 2015;24(22): S12–S18. doi:10.12968/bjon.2015.24.Sup22.S12.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Laura Williamson, BSN, RN, , and Maggie Mae Baenziger, BSN, RN, , Wound Care, Chicago, IL

BACKGROUND: Heel injury (HI) is the most prevalent type of hospital-acquired pressure injury. In addition, a study of 450,000 patients found that the heel accounted for 41% of deep tissue injury. Risk factors associated with the development of heel ulcers include agitation, diabetes, surgery, immobility, arterial insufficiency, age, and poor nutrition. The most effective evidence-based practice (EBP) to prevent HI is the use of heel suspension to elevate and off-load the heel. Associated best practices include patient positioning to prevent both foot drop and maintain leg alignment. In 2015, we experienced an increased incidence of HIs. The goal of our project was to implement EBP and decrease HIs. METHODS: We developed an algorithm to identify patients at risk for HI and implemented it in 5 clinical units. At-risk criteria included nonambulatory, Braden Scale score of less than 15, and 2 or more comorbid conditions. A boot designed to off-load the heel, reduce plantar flexion, prevent lateral rotation, and stay in place was used on patients who met the at-risk criteria. All staff were educated on the new algorithm, and compliance was tracked. RESULTS: In the 11 months prior to implementation, we had a monthly HI incidence of 1.8 (20 total). Since implementation, we have had 10 consecutive months without an HI. Compliance with the new EBP in our highest-risk patients (critical care and rehab) was 100%, with 80% and 50% in the 2 medical-surgical units (overall 82%). CONCLUSION: The implementation of the algorithm was associated with a decrease in monthly HI incidence from 1.8 to 0. In addition to avoidance of pain and suffering for patients impacted by HI, numerous data support that the overall cost of prevention is far less than the cost of treatment of hospital-acquired pressure injury. Our plan is to continue with the new EBP and improve overall compliance.

Langemo D. Heel Pressure Ulcers: 2014 International Pressure Ulcer Prevention & Treatment Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel; 2014.

VanGilder 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):39–45.

Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4):385–392.



Elizabeth Culver, BSN, RN, CWON, , Patricia Pezzella, BSN, RN, CWON, , Julia Langin, BSN, RN, CWON, CMSRN, , and Linda Abbott, DNP, RN, CWON, AOCN, , Nursing, Iowa City, IA; and Laura Phearman, BSN, RN, CPNP, , University of Iowa Children's Hospital, Iowa City, IA

PURPOSE: The purpose of this project was to implement an evidence-based intervention to reduce hospital-acquired heel pressure injuries using a 5-layer soft silicone foam border dressing. OBJECTIVE/RELEVANCE/SIGNIFICANCE: Despite increased scrutiny of hospital-acquired pressure injuries and the agreement that heel pressure injuries should be a “never” event, they continue to occur. Despite documented benefits of heel protection boots/devices, there are patients who cannot or will not wear them. A lower-cost alternative that has been documented as effective for the prevention of heel pressure injuries is available. STRATEGY AND IMPLEMENTATION: At a large Midwestern tertiary medical center, a 5-layer soft silicone foam border dressing designed to protect heels was piloted on units with higher rates of heel pressure injuries than those in the rest of the organization. A policy and procedure was developed and proposed to the unit councils. When there was agreement to pilot the dressing on the unit, training was conducted by the Product Sales Representative and an instructional flyer was posted on each unit participating in the trial. Dressings were made available on the units for use with patients at risk as identified in the policy. Dressings were changed every 3 days if the patient remained at risk for heel pressure injury development. EVALUATION: For the 6 months before the pilot, the number of heel pressure injuries reported was 19. For the 6 months during the pilot, the number of heel pressure injuries reported was only 10. The number of reported heel pressure injuries went from 7 to 3 in the intensive care settings.

Clegg A, Kring D, Plemmons J, Richbourg L. North Carolina wound care nurses examine heel pressure ulcers. J Wound Ostomy Continence Nurs. 2009;36(6):635–639.

Cichowitz A, Pan WR, Ashton M. The heel: anatomy, blood supply, and the pathophysiology of pressure ulcers. Ann Plast Surg. 2009;62(4):423–429.

Fowler E, Scott-Williams S. Practice recommendations for preventing heel pressure ulcer. Ostomy Wound Manage. 2008;54(10):42–57.

Gilcreast DM, Warren JB, Yoder LH, Clark JJ, Wilson JA, Mays MZ. Research comparing three heel ulcer-prevention devices. Wound Ostomy Continence Nurs. 2005;32(2):112–120.

Hill-Rom. International Pressure Ulcer Prevalence Survey. Chicago, IL: Hill-Rom; 2013–2014.

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



Laura Phearman, BSN, RN, CPNP, , University of Iowa Children's Hospital, Iowa City, IA; and Patricia Pezzella, BSN, RN, CWON, , Julia Langin, BSN, RN, CWON, CMSRN, , Michelle Greve, BSN, RN, CWON, CMSRN, , Elizabeth Culver, BSN, RN, CWON, , and Linda Abbott, DNP, RN, CWON, AOCN, , Nursing, Iowa City, IA

PURPOSE: The purpose of this project was to improve documentation by the WOC nurses for more effective communication and tracking of productivity. OBJECTIVE/RELEVANCE/SIGNIFICANCE: The WOC nurses quantify work by tracking productivity. Productivity was tracked through a computer spreadsheet program requiring team members to document in addition to documenting in the electronic medical record (EMR). With increases in volume and complexity of patients at a Midwest academic medical center, the need for tracking productivity with increased efficiency arose, not only to maintain current staffing but also to support additional staff. There were concerns that the spreadsheet may be subjective and could miss work. STRATEGY AND IMPLEMENTATION: A mechanism for tracking productivity used by other nursing services served as a template for the WOC nurses. The team identified necessary data to be captured through regular meetings. The WOC team developed a new documentation system, or “navigator,” within the EMR to provide one location for all needed documentation. The WOC nurses collaborated with the informatics staff to build the “navigator” and to create an automatic monthly report. The WOC nurses modified the “navigator” after viewing the first few reports. The report illustrates work volume as well as complexity for each WOC nurse and time spent with each patient. EVALUATION: The WOC team receives a monthly report of patient-related activity including volumes, time spent, and services performed. The new EMR captures all necessary variables for reporting hospital-acquired pressure injuries to streamline skin surveys. Aggregate data are available for administrative planning and also as individual productivity reports used for performance evaluations and goal setting. The reports provide information on trends and changes in demographics for the service. Although nonpatient care activities are not captured in the navigator, it illustrates the demands on the team supporting an addition of 1.5 full-time equivalents for the WOC service over the past 2 years.

Wound—Product Selection and Innovations



Wendy Kinsey, RN, OCN, CWOCN, , Melissa S. Hiscock, BSN, RN, OCN, CWOCN, , and Kathleen O'Hearn, MSN, RN, CWOCN, , WOC Nursing, Buffalo, NY; Judith Del Monte, MS, CPHQ, , Jennifer Lindemann, MSN, RN, OCN, , Anna Foster, BSN, RN, OCN, , Deanna Capozzi-Meyers, BSN, RN, , April Meyer, BSN, RN, CCRN, , and Jessica French, RN, FNP, , Nursing, Buffalo, NY; and Thomas Stewart, PhD, , Buffalo, NY

PURPOSE: In our hospital, a WOC nurse referral was required to obtain a support surface other than the standard one, which could result in a delay in patient care. A retrospective analysis of our pressure injury (PI) data compared to bed rental invoices revealed support surface changes were often made after the development of a PI. A support surface algorithm was developed to provide a user-friendly guide for the bedside nurse to assist with selecting and obtaining the correct support surface for her patient. The tool combines published evidence with the support surfaces available at our hospital and instructions for obtaining the surface. Administrative support was required to coordinate the efforts of several departments to utilize support surfaces and low air loss pumps, which were in storage and unavailable to staff until the algorithm was developed. Procedures were developed for transporting, storing, and cleaning the surfaces. OBJECTIVES: Our aim was to empower the bedside nurse to select the appropriate support surface using a tool that concentrates on the Braden subscale scores for moisture and mobility, in conjunction with a full nursing assessment. The guideline combines easy-to-follow pictograms with a priority ranked list for appropriate support surfaces. The flip side has photographs of the support surfaces and details how to obtain them so that previously purchased equipment could be utilized. OUTCOME: The bedside nurse is now enabled to select the correct surface based on evidence. Support surface usage (including rentals) was monitored and evaluated, and a cost increase was identified despite utilizing already purchased equipment. This increase was attributed to the proactive procurement of support surfaces and providing best practice. The increase also confirmed the necessity for more advanced surfaces, particularly in the critical care areas, and trials for capital purchase were begun.

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

McNichol L, Watts C, Mackey D, Beitz J, Gray M. Identifying the right surface for the right patient at the right time: generation and content validation of an algorithm for support surface selection. J Wound Ostomy Continence Nurs. 2015;42(1):19–37. doi:10.1097/WON.0000000000000103.

Wound—Management of Complex Wounds



Mollie Hall, CWOCN, , Jennifer Roark, CWOFN, , Melissa Hall, Student, , Madeline Pendergrass, CWON, , and Ivy Razmus, CWOCN, , Wound Ostomy, Tulsa, OK

CONTEXT: Each year, patients are admitted to the inpatient acute and critical care setting with wounds. Patients with wounds are often admitted for other comorbidities. Patients admitted to this health system with a wound diagnosis comprised 6329 patients admitted to the health care facility in the past 12 months. This inpatient facility did not have a system for addressing inpatient complex wounds, prolonging their length of stay (LOS). DESCRIPTION: A cost analysis of patients with a diagnosis of wounds was conducted for a 1200-bed inpatient health care facility over the previous 12 months. OBSERVATION: The average LOS for patients with a diagnosis of wounds was 8.99. A reduction of 0.1 LOS for these patients wound result in a total cost savings of $1,012,007 annually based on a cost per day of $1,599.00 per patient. Nine percent of the patients were uninsured, which would account for $91,080.63 in cost savings. DISCUSSION: The information gained from this cost analysis provided evidence for the development of an interdisciplinary complex wound service. A system was developed to electronically consult the Complex Wound Service, which included a team consisting of a physician, a physical therapist, and WOC nurses. An order set and electronic triggers in the electronic health record were created so that complex wound could be addressed, thereby decreasing LOS for these patients.

Saint Francis Health System. 2016.

Wound—Product Selection and Innovations



Becky Greenwood, BSN, RN, CWOCN, , Education/Quality Department, South Jordan, UT; and Annette Gwilliam, BSN, RN, CWCN, ACHRN, , Wound Care Coordination, Orem, UT

PROBLEM: Wounds are a major problem at the end of life, affecting nearly one-third of patients.1 Hospice and palliative care wound management requires a different mind-set than traditional wound care, yet is based on the same fundamental scientific principles. “Goals for palliative wound care are well established in the literature including: pain relief, infection prevention, exudate management, odor management, improved comfort, and enhance dignity.”2,3 Appropriate wound cleansing and wound bed preparation will decrease bacteria and necrotic tissue that cause odor, exudate, inflammation, and pain. IMPORTANCE: There is an increased need to treat the hospice patient's wound appropriately. Regulatory bodies for hospice can potentially place the agency in “immediate jeopardy.” If inappropriate treatment of wound palliation is discovered, the agency can be shut down.4 More important is that inappropriate wound care contradicts the very mission of providing hospice care. PROPOSED SOLUTION: Replace coarse, scratchy gauzes and washcloths with a monofilament wound preparation device (MWPD). Perform the procedure 1 to 2 times weekly for 2 to 5 minutes using saline or hypochlorous solution. We incorporated MWPD into all hospice wound care order sets as a standard of care for wound and periwound cleansing to enhance wound palliation. RESULTS: Patient A was a 78-year-old female with such extensive odor and drainage that the assisted living staff would not enter her room. We implemented MWPD with hypochlorous acid and within 1 week the odor was eliminated and the drainage significantly decreased. Patient B was a 53-year-old female with a painful, draining wound. By implementing MWPD, the wound bed was cleaned and it began to heal. After these successes, MWPD has been used on dozens of patients with the same positive outcomes. CONCLUSION: Although our results are mainly subjective and qualitative, incorporation of this procedure has enhanced our patient's hospice care, dignity, and quality of life.

Tippett AW. Palliative wound treatment promotes healing in hospice. Published 2015.

Hughes RG, Bakos AD, O'Mara A, Kovner CT. Palliative wound care at the end of life. Home Health Care Manage Pract. 2005;17(3):196–202. doi:10.1177/1084822304271815.

Naylor W. Guidelines for wound management in palliative care. http://

CMS regulation, State Operations Manual Appendix Q—guidelines for determining immediate jeopardy. Published February 14, 2014.



Becky Greenwood, BSN, RN, CWOCN, , Education/Quality Department, South Jordan, UT; and Annette Gwilliam, BSN, RN, CWCN, ACHRN, , Wound Care Coordination, Orem, UT

The use of 2- or 4-layer compression wraps to manage edema and aid in wound healing is common in the treatment of edema and venous insufficiency.1 Disposable compression wraps are costly and require specialized training and skill to apply. Due to the nature of the disease, after wounds have healed, patients will need continued compression to prevent reoccurrence of ulcerations. The nursing care and product costs were increasing; therefore, we decided that a solution for our agency was to substitute the 2-/4-layer compression products with a reusable Velcro wrap. We worked closely with the wound care physicians, and once drainage and edema decreased, we initialed the reusable Velcro closure compression wrap as a substitute for disposable compression wraps. We also taught the patient and/or family how to apply the Velcro garment. To this date, we have initiated the protocol on 10 patients, with very positive outcomes. All of the patients continued to have their edema managed, and the wound measurements decreased as they continued to heal. A survey of the patients found that the garments were “comfortable” and “easy to wear.” A nursing survey indicated they felt the wraps were “easy to use” and “saved time during wound treatment.” We found significant cost savings, as the Velcro system was covered by insurance, if ordered while the patient had open wounds. This saved our agency $100 to $150 per week in compression products alone. With growing costs of healthcare, the use of a reusable compression garment will reduce the cost of treatment while maintaining good-quality outcomes. The added benefit to the patient is the use of the Velcro compression system as a maintenance garment once the wounds have healed, decreasing the risk for recurring ulcerations.

1. Ratliff CR, Yates S, McNichol L, Gray M. Compression for primary prevention, treatment, and prevention of recurrence of venous leg ulcers an evidence-and consensus-based algorithm for care across the continuum. J Wound Ostomy Continence Nurs. 2016;43(4):347–364.

Continence—Issues in Bladder and Bowel Continence Management



Jeanne Arseneau, MSN, RN, CWOCN, , Wound, Ostomy & Continence Department, Rosedale, MD

Fecal incontinence with diarrhea in the acute care setting requires careful and attentive management to prevent skin breakdown and infection. The use of an internal fecal management system (IFMS) diverts liquid or semiliquid stool into a collection bag, but it has potential risks of causing serious patient harm. At a community hospital in the Northeast, it was discovered that the IFMS was used very frequently, the documentation system did not include a section for the IFMS, and the hospital policy needed updating and clarification for the role of the nurse and the medical staff. During the process of developing the new documentation and policy update, a safety alert was received from our Corporate division concerning 2 rectal perforations in a sister hospital. The safety alert accelerated the completion of the new documentation and the policy. Education was disseminated to the nursing and medical staff on the new policy regarding indications, contraindications, medication reconciliation, use of fecal pouch prior to considering the IFMS, medical staff assessment of anal sphincter tone, and guidelines for discontinuation. The new change in practice resulted in decreasing the IFMS usage from 391 to 122 and cost savings of $43,000 for the year.

Guidelines for the management of fecal incontinence with Flex-Seal SIGNAL Fecal Management System (FMS). http:// ap-012616-us.pdf. Accessed May 15, 2015.

Mulhall AM, Jindal SK. Massive gastrointestinal hemorrhage as a complication of the Flexi-Seal fecal management system. Am J Crit Care. 2013;22(6):537–543.

Wilson 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(1):61–69.

Wound—Management of Complex Wounds



David Crumbley, CWCN, , Nursing, Auburn, AL

PURPOSE: From 2009 to 2011, there were 112 cases of invasive fungal infections (IFIs) among US military personnel who suffered complex blast injuries in Afghanistan. The hallmark of IFIs is recurring tissue necrosis with further loss of tissue. Initial wound management for these IFIs was provided via negative pressure wound therapy (NPWT) with silver-impregnated reticulated open cell foam (ROCF) dressings. However, at a major military medical center in Bethesda, Maryland, this treatment was not proving effective in reducing the tissue necrosis or fungal growth associated with these wounds. This was evidenced by the visualization of new growths of black mold patches on wound tissue between routine 48- and 72-hour debridements. OBJECTIVE: Orthopedic and trauma surgeons sought out assistance from the WOC nurse to develop a solution that would help eradicate fungal growth and reduce tissue necrosis between debridements. OUTCOMES: The recommendation by the WOC was to use NPWT and periodically instill a solution of 0.025% dilute sodium hypochlorite into the wound. This therapy was accomplished by using a commercially available NPWT device capable of instilling chemical solutions directly into the wound. Sodium hypochlorite was chosen based on its antifungal properties. Initial results were very favorable in the first wounds managed using this technique. Mold growth in the wounds between debridements was significantly reduced with the addition of the dilute sodium hypochlorite solution. Anecdotally, the surgeons reported significant reductions in tissue necrosis and tissue loss. After the success in the first trials using dilute sodium hypochlorite solution in wounds, all successive wounds suspected of IFI were managed in this manner. The practice of using NPWT with the instillation of dilute sodium hypochlorite solution has now become the treatment of choice for military medicine in the management of invasive fungal wound infections.

Cannon JW, Hofmann LJ, Glasgow SC, et al Dismounted complex blast injuries: a comprehensive review of the modern combat experience. J Am Coll Surg. 2016;223(4):652–664.e8. doi:

Lewandowski L, Purcell R, Fleming M, Gordon WT. The use of dilute Dakin's solution for the treatment of angioinvasive fungal infection in the combat wounded: a case series. Mil Med. 2013;178(4):e503–e507.

Lewandowski LR, Weintrob AC, Tribble DR, et al Early complications and outcomes in combat injury-related invasive fungal wound infections : a case-control analysis. J Orthop Trauma. 2016;30(3):93–99. doi:

Radowsky JS, Strawn AA, Sherwood J, Braden A, Liston W. Invasive mucormycosis and aspergillosis in a healthy 22-year-old battle casualty: case report. Surg Infect. 2011;12(5):397–400. doi:

Rodriguez CJ, Weintrob AC, Shah J, et al Risk factors associated with invasive fungal infections in combat trauma. Surg Infect. 2014;15(5):521–526. doi:

Tribble DR, Rodriguez CJ. Combat-related invasive fungal wound infections. Curr Fungal Infect Rep. 2014;8(4):277–286. doi:

Tribble DR, Rodriguez CJ, Weintrob AC, et al Environmental factors related to fungal wound contamination after combat trauma in Afghanistan, 2009-2011. Emerg Infect Dis. 2015;21(10):1759–1769. doi:

Warkentien T, Rodriguez C, Lloyd B, et al Invasive mold infections following combat-related injuries. Clin Infect Dis. 2012;55(11):1441–1449. doi:

Weintrob AC, Weisbrod AB, Dunne JR, et al Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification. Epidemiol Infect. 2015;143(1):214–224.

Wound—Product Selection and Innovations



Rene Amaya, MD, CWSP, , Pearland, TX

Negative pressure wound therapy (NPWT) is a well-recognized wound care intervention. Its efficacy has also been illustrated in the pediatric population. In premature infants, guidelines for the use of NPWT are limited. Safety is an inherent concern when a wound care intervention is applied in this fragile population. Advanced wound dressings and devices may cause additional skin trauma due to the immature nature of their skin. The purpose of this study was to assess the safety and efficacy of an alternative application technique of an NPWT device in premature infants. It was the author's hypothesis that this alternative technique would remain effective and, more importantly, reduce the risk for additional skin trauma in these patients. Four premature infant cases are presented. Patients ranged from 23 to 28 weeks' gestational age. Each infant suffered intravenous extravasation injuries, resulting in deep full-thickness wounds. Injuries arose secondary to extravasation of total parenteral nutrition or antibiotics. Due to significant tissue loss as a result of the extravasation injury, NPWT was initiated to promote granulation. Due to the diminutive size of these patients and their immature skin, the NPWT device was applied in alternative manner to reduce the amount of adhesive film dressing required to attach these bulky devices to their bodies. Direct contact with the device foam and adhesive dressing was limited to the wound bed itself, and tubing and remaining device components were connected away from the patient utilizing simple supplies available in the neonatal intensive care unit. This alternative NPWT dressing was replaced every 2 to 3 days as per standard guidelines. In all 4 cases, the NPWT device functioned normally and excellent wound granulation was obtained. No complications were encountered in the infants. This study illustrates the effective use of NPWT in premature infants while focusing on preventing additional injury by utilizing an alternative application technique.

Baharestani M, Amjad I, Bookout K, et al V.A.C. therapy in the management of paediatric wounds: clinical review and experience. Int Wound J. 2009;6(suppl 1):1–26.

Ostomy—Psychosocial and Quality-of-Life Aspects



Lisa Berning, BSN, RN, CWOCN, CFCN, , Wound Ostomy Continence, Cincinnati, OH

With an increase in laparoscopic colorectal surgeries and enhanced recovery protocols, WOC nurses face even greater challenges to educate and help new ostomates adjust psychologically to living with an ostomy. OBJECTIVE: In our 500+-bed facility, we typically have 3 or 4 days, including weekends, postsurgery to ensure our new ostomates and their caregivers are fully prepared to care for their ostomy before discharge. These new ostomates are postanesthesia; on pain medication with residual postoperative pain; have disrupted sleep; and are in emotional/psychological turmoil regarding the ostomy. Collaborating with surgeons, the surgical nurse practitioner, and Presurgical Services staff, we developed an early referral process enabling the WOC nurse to meet with potential new ostomates and their caregiver(s) 2 to 4 sessions prior to surgery. This process provides the opportunity to build a trusting supportive rapport with patients and their caregiver(s) and assess for optimal learning styles and psychosocial and physical needs and enables initiation of measures to meet postdischarge needs in addition to providing the patient and caregiver(s) time to become familiar with the appliances and adjust to living with an ostomy all prior to surgery. In order to ensure positive outcomes and ease of adjusting to living with an ostomy, we provide individualized postdischarge support including outpatient visits, follow-up calls, and ongoing coordination of care with home health and/or post–acute care staff. OUTCOMES: This process has improved overall patient outcomes evidenced by early independence in ostomy care; effective teach back of all education during review sessions postoperatively; and positive patient and caregiver feedback. As WOC nurses, we must adapt our educational programs and methods to continue to meet the needs of our new ostomate patients and their caregiver(s).

Colwell JC, Gray M. Does preoperative teaching and stoma site marking affect surgical outcomes in patients undergoing ostomy surgery? J Wound Ostomy Continence Nurs. 2012;34(5):492–496.

Gravante G, Elmussareh M. Enhanced recovery for colorectal surgery: practical hints, results and future challenges. World J Gastrointest Surg. 2012;4(8):190–198.

Wound—Dermatological Management/Issues



Carol Hall, BSN, RN, CWOCN, , U.T. Southwestern Hospital at Zale Lipshy, Dallas, TX; Shelli Chernesky, MBA, MSN, RN, CCRN, , Apheresis, Dallas, TX; and Jennifer Wintz, BSN, RN, QIA, , Tomas Armendariz, BSN, RN, , Nicole DeSimone, MD, , and Ravi Sarode, MD, , Apheresis, Dallas, TX

OBJECTIVE: Extracorporeal photopheresis (ECP) is an approved treatment of cutaneous T-cell lymphoma (CTCL) and acute/chronic graph versus host disease (GVHD) following hematopoietic stem cell transplantation. These patients need skin monitoring for ECP response. In the past, only descriptive terms were written in the patient's documentation; therefore, we began photographic documentation of skin changes to determine if the photographs would provide better assessment of skin progress in response to treatment. METHODS: ECP therapy is protocolized and usually consists of a total of 32 or more treatments over 10 months or longer. The course may be continued depending on response to the ECP. A digital camera with removable memory card was purchased for the apheresis clinic. A baseline photograph is taken of the patient prior to ECP therapy initiation. Photographs of the same sites of skin and same distance from the affected area are taken for accurate assessment of clinical response every eighth treatment of GVHD and once a month for CTCL, or with any new skin changes as needed. The photographs are downloaded to the electronic medical record by the apheresis nurse, with an accompanying note describing the color, texture, size, and area of skin involvement as well as patient's description of itching and/or pain. The physician assesses the progress during each visit and corroborates the changes. CONCLUSION: So far, 14 cases have been entered since implementation in November 2016. Four had their treatment plans revised to improve the skin involvement of their disease processes. Continuous photographic monitoring of skin changes allows for accurate assessment and monitoring of response to ECP. This documented process enables clinicians to assess the progress of the patient objectively throughout the therapy and to allow for adjustments to the ECP plan of care.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Carol Hall, BSN, RN, CWOCN, , U.T. Southwestern Hospital at Zale Lipshy, Dallas, TX; Claudia Engle, RN, CWOCN, CFCN, , WOC Nursing, Dallas, TX; and Emily Flahaven, MSN, RN, CAHIMS, , Infomatics, Dallas, TX

BACKGROUND: The hospital electronic skin documentation changed, leading to confusion and dissociation of care of patients with pressure injuries. A housewide survey showed that staff were no longer receiving education regarding staging of pressure ulcers and were inconsistent regarding documentation of skin problems. METHODS: A skin documentation multidisciplinary task force was formed in April 2016 to meet weekly to evaluate the existing skin documentation and to make recommendations for change. One goal was the review of best practices in skin documentation, nursing interventions, and standing medical orders, as well as to develop a plan for implementation. A skin bundle for pressure ulcer prevention was developed that included a best practice alert within documentation for any patient with a Braden Scale score of 18 or below. A clinical pathway was streamlined to guide nursing staff for the treatment of pressure ulcers, skin tears, and moisture-associated dermatitis. RESULTS: Education was created with a go-live date of September 19, 2016, including classes designed to review pressure ulcer staging, treatment, and documentation—these were mandatory for skin representatives and assistant nurse managers. Two skin representatives were assigned from each unit to be skin champions and superusers for documentation. Pressure ulcer staging modules and testing within the electronic training program were mandatory for all nursing staff. In conjunction with the skin documentation being revised, the event reporting system was revamped to include a debriefing tool for any hospital-acquired pressure ulcer to determine causes and if further prevention methods should be developed.

National Database of Nursing Quality Indicators

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



Maureen Rosette, BSN, RN, CWOCN, , Nursing Administration, Troy, MI

BACKGROUND: As health care in the United States moves to a value-based purchasing model, the WOC nurse provides a vital role in necessary cost containment and cost avoidance. By collaborating with the supply chain and purchasing, the WOC nurse has a golden opportunity to provide a voice driven by outcomes and evidence. PURPOSE: The WOC Advisory Group provides a forum for the certified RNs and nurse practitioners to develop policies, treatment guidelines, and cost-effective product solutions for the Beaumont Health Organization. This group serves as the content experts for WOC conditions, providing evidence-based product selections, patient and staff education, and policy development. METHOD: The WOC Advisory Group was started to coordinate best practices, streamline formulary, and combine WOC forces within the founding Beaumont Hospitals (Troy, Royal Oak, Grosse Pointe). Quarterly meetings began in 2014. WOC nurses streamlined the ostomy formulary and shared teaching materials for new ileostomates. Over time, with the alignment of the Oakwood and Botsford systems, the WOC group invited WOC nurses from all 8 hospitals to the forum, including home care, outpatient wound clinics, and clinical nurse specialists. With the alliance, there came a new process for materials management. Director of Beaumont Health supply chain was invited to a meeting to describe the new process for ordering. She saw the value in our work group and invited the WOC Advisory Group to be a part of the Medical Vat for the system. RESULTS: • Ostomy formulary across the 8 systems; • Patient teaching for new ileostomates; • Pressure ulcer prevention policy, with universal guidelines, respecting different practice settings; • Developed bedside tool, complementing the new Pressure Ulcer Prevention policy; • Process for product trials across system; • The WOC Advisory Group now a member of the medical VAT and involved in product evaluations, eliminating duplication, and providing outcome-based solutions.

Russell J. Clinical and operational collaboration in value analysis. Nurs Manage. 2013;44(9):16–20.

Russell J. Nurses as value analysis facilitators. Nurs Manage. 2013;44(2):53–55.

Barlow RD. Migrating toward value analysis 2.0. Healthc Purchasing News. 2013;37(10):12–24.

Wound—Preventative Practices New



Aurora Monica Tweddell, BSN, RN, WOCN, , and Robin Gooding, RN, WCC, OMS, , Education, Mission Hills, CA

PURPOSE: The purpose of this project was to enhance the “S” portion of the Skin Bundle to create a standardized process for skin inspection beginning at the time of admission or patient transfer between units. The goal was to decrease our hospital-acquired pressure injuries that are reported on a monthly basis to the quality management team. The hospital-acquired pressure injury rate in the first quarter of 2012 was at 2.23%; this prompted the introduction of “Kicking It Up a Notch” as a new practice. Continuing with monthly skin checks house-wide shows the rocky but steady decrease in the decline of hospital-acquired pressure injuries through 2015 at last quarter ended at 0.51%. INTERVENTION: A house-wide practice was introduced in the first quarter of 2013. Our practice of taking a photo of wounds when a patient was admitted was increased by “Kicking It Up a Notch”. Kicking It Up a Notch targeted the nurse who was admitting a patient with the task of advising the patient that the current practice was to take a photo of his or her sacral area even if there was no skin impairment. This practice was also extended to patients being transferred within units. The photo requires 2 RN verification signatures. Included in this new practice was the addition of a sacral dressing if the patient met a specific prevention criterion along with a support surface. EVALUATION: Pressure injury data are collected by the Wound and Skin Team on a monthly basis. The data collected are communicated with the quality team on a quarterly basis for dissemination and reporting to the NDNQI.

Professional Practice—Satisfaction Measurement



Teresa “Ellen” Woodcock, BSN CWON, , WOCN, Columbus, IN

PURPOSE: The purpose of this abstract was to assess the effectiveness of the WOC Tip of the Day in improving staff nurse education, comfort, and prevention of skin breakdown. The monitoring and prevention of skin breakdown are a priority in nursing care. Research has shown that a nurse's lack of knowledge in skin care can have a negative impact on patient care. The WOC Tip of the Day began as a way to communicate by e-mail brief and concise education on skin, wound, and ostomy care in the same way to a larger amount of nurses and nursing assistants. METHOD: At a level II rural hospital with an average inpatient daily census of 95, a survey link was sent to the e-mail distribution list of nursing staff who receive the tips. The tips provided are based on education need noted that day or week. The tips fit on 1 page and most had pictures. Links and references were often provided for those interested in reading further. Topics varied from skinfold care, skin tears, and ostomy, wound, and pressure ulcer documentation to education on how to use products, etc. The survey provided qualitative data from 5 questions and had 42 anonymous participants. RESULTS: Participant answers: 93% read the tips; 88% find the tips helpful; and 83% feel more confident in providing skin care as a result of the tips. Ninety percent of the participants felt patients have benefitted from the WOCN best practice tips. CONCLUSION: A majority of those who responded to the survey indicated that they do read the tips, find them helpful, have changed practice, and feel more confident in the care of their patients.

Boudreau L, Maurer R, Reft J, Larson S, Hancock B, Kleinpell R. Assessing the impact of nursing education on skin and wound care. J Wound Ostomy Continence Nurs. 2009;36(3):3437.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Liesel Miller, BSN, RN, CWON, , Kimberly Hanson, BSN, RN, CWON, , and Gina Jansen, BSN, RN, , Advance Practice Nursing–Wound Care, Loma Linda, CA; Barbara Yvonne Fankhanel, BSN, RN, CWOCN, , and Eileen Martois, BSN, RN, CWOCN, , Loma Linda University Medical Center, Loma Linda, CA; Jessica Field, BSN, RN, , Cardiothoracic ICU, Loma Lindad, CA; and Penny Amornvut, MSN, RN, CCRN, , Cardiac/Cardiothoracic, Loma Linda, CA

The effectiveness of a unit-based Skin Care Champion Program (SCCP) to promote professional nursing practice and decrease adverse outcomes such as hospital-acquired pressure injuries (HAPIs) is evident in current literature. Following the example of other large academic medical centers, an SCCP was implemented on 3 cardiothoracic/cardiac inpatient units for the purpose of reinforcing the significance of the role of the bedside RN as a skin care champion while partnering with the certified WOC nurses to achieve state- and nationwide best practices. The program's objectives were to: • Decrease HAPIs and promote quality of care; • Increased staff education and innovation; • Move from culture to treatment to a culture of prevention. HAPIs decreased by half 6 months after SCCP implementation, including no reportable HAPIs (stage 3, stage 4, and unstageable) for another 6 consecutive months per California state regulations. A survey of skin champions on all 3 units disclosed increased professional satisfaction, ability to assess pressure-related versus non–pressure-related wounds, ability to stage pressure ulcers, and significantly improved individual practice for pressure injury prevention (4.22, 4.44, 4.44, and 4.67 weighted averages per question, respectively). A survey of unit staff showed that 65% perceived improved patient outcomes after SCCP implementation, with 77% reporting an improvement in their own practice for pressure injury prevention; 66% and 68% reported increased confidence in pressure injury recognition and staging, respectively. A unit-based SCCP demonstrates effectiveness in decreasing HAPI rates, promoting nursing satisfaction and professional practice, while increasing confidence both among champions and bedside staff when assessing pressure injuries. An estimated $10,500 was invested to train 12 champions over 2 weeks that resulted in a potential $150,000* in cost savings over 6 months for HAPI prevention.

Carson D, Emmons K, Falone W, Preston AM. Development of a pressure ulcer program across a university health system. J Nurs Care Qual. 2012;27(1):20–27. doi:10.1097/NCQ.0b013e3182310f8b.

Centers for Medicare & Medicaid Services Medicare Program. Proposed changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Proposed additions to hospital acquired conditions for fiscal year 2009. Published 2009. Accessed February 19, 2009.

Tellson A, Hoffman M. Skin champions: save our skin SOS. Paper presented at: American Nurse Association Annual Conference. Published 2016.

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



Tina Meyers, MBA, BSN, CWOCN, , Education, Conroe, TX

BACKGROUND: The role of the bedside nurse is becoming more and more complicated and demanding each year. Although demands have increased in nursing care, most patient-to-nurse ratios have remained the same. In order to help nurses continue to provide quality care, it is imperative to have assistance from qualified employees such as the certified nursing assistant (CNA). AIM: The aim of this project was to increase the nursing assistants' knowledge of pressure ulcer prevention and ostomy skills to be able to bring a higher level of practice to the workforce. METHOD: A WOC nurse was hired by an Independent School District to create and implement a CNA program at the high school level. The WOC nurse provided instruction and guidance through the CNA curriculum with an extensive focus on pressure ulcer prevention and ostomy care. RESULTS: Students who qualified for the nursing assistant certification exam were prepared for testing. Students who completed the exam were hired in hospital settings where they showed increased knowledge of pressure ulcer prevention, ability to help prevent pressure ulcers, and care for the ostomy. CONCLUSION: Pressure ulcers still remain to be an issue in health care. It is imperative to make sure nurses are being exposed to prevention methods and provided team members who have skin management training. By having an emphasis on skin management-specific curriculum for the high school student who desires to be a CNA, it encourages only overall improvement in the healthcare process.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Marianne Banas, MSN, RN, CCTN CWCN, , and Jennifer Sala, ADN, RN, , University of Chicago Medical Center, Chicago, IL; and Susan Solmos, MSN, RN, CWCN, , Center for Nursing Professional Practice and Research, Chicago, IL

PURPOSE: To decrease hospital-acquired pressure ulcers (HAPUs) in critically ill adult patients. SIGNIFICANCE: Patients with HAPUs have poor outcomes such as pain, infection, and almost 80,000 in-hospital deaths each year. At an academic medical center, traditional approaches to introducing new information and practice prompts for nursing staff included posters, e-mails, and in-services. However, it was unclear whether posters or e-mails were reaching all nursing staff and in-services of up to 30 minutes were resource intensive. METHODS: Developed strategy of brief targeted in-services to reinfuse knowledge related to HAPU Prevention Bundle (evidence-based [EB] prevention interventions) or create awareness of key issues in advance of EB practice changes. Beginning in Q4 FY15, 2 intensive care unit staff nurse/members of the Senior Skin Care Team provided 5-minute in-services twice per month. Content focused on key clinical issues identified during HAPU event analyses, Skin Care Team feedback, or direct observation by the certified wound and continence nurse Posters and handouts were used to reinforce the key messages of the 5-minute in-services. Topics included appropriate placement of silicone sacral dressing, use of heel boots, medical device–related pressure ulcer (MDRPU) awareness campaign, and interventions to prevent most frequent MDRPUs. Some topics were repeated more than once during the intervention period. The number of HAPU cases was tracked 8 months pre- and postimplementation of 5-minute in-services strategy. OUTCOMES: By investing in 8 hours per month of senior Skin Care Team member time, a 53% decrease (from 30 to 14) in the number of adult critical care HAPU cases postimplementation has been noted. CONCLUSIONS: Peer-to-peer teaching was a successful approach, and 5-minute in-services are an effective way to reach staff during their shift. Based on the success of this initiative, this strategy should be included as part of the HAPU Prevention Bundle to reinfuse knowledge and build EB practice.

Ostomy—Stomal/Peristomal Complications



Alanna Valadez, MBA, MSN, RN, PHN, APRN, CNP, CWOCN, , WOC Program, St Paul, MN, Kathleen Borchert, MS, ACNS-BS, CWOCN, CFCN, , WOC Program, Minneapolis, MN; and Lynne Bausman, RRT, , RT, St Paul, MN

TOPIC: Our long-term acute care facility has a high prevalence of tracheostomy patients. A guide was developed for our multidisciplinary team to assist with correctly identifying stomal/peristomal skin concerns at the tracheostomy site. PURPOSE: The WOC team noted an increase in tracheostomy consults. Nursing staff, respiratory therapists (RTs), and physicians were identifying concerns incorrectly at the trach, classifying concerns mostly as pressure related. Nursing wanted the WOC team to assess all concerns, as staff did not feel confident differentiating between erythema related to pressure injury, blanchable versus nonblanchable, and other concerns. The increased calls and incorrect skin assessments prompted the WOC team and lead RT to partner. Gaps were found in staff education and visual teaching tools. Our improvement plan was to develop a visual teaching tool. OBJECTIVE: To develop an educational document that provided guidance to staff on Tracheostomy Skin Abnormalities. The document included a description of stomal/peristomal skin concerns, reason concern occurs, photo of concern, interventions, and how to document staffs' assessment/interventions in the electronic health record. After the tool was developed, it was presented during huddle to nursing staff and RTs and a laminated copy hung on respiratory unit as a quick reference guide. OUTCOME: Staff provided positive feedback and consistently identified stomal/peristomal skin concerns correctly at the tracheostomy site. Staff members were able to express the new concerns that could be assessed during a weekly WOC visit versus a more urgent issue, such as a suspected pressure injury under a tracheostomy faceplate. The new Tracheostomy Skin Abnormalities tool helped staff intervene with prevention sooner; however, the WOC nurses began to note dressings being placed incorrectly under the faceplate. A second document was developed, Off-loading the Tracheostomy Faceplate, which assisted staff with applying the correct pressure injury prevention intervention under respiratory equipment and in time decreased WOC consults.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Rose Raizman, MSc, MNurs, RN-EC, CETN, , Professional Practice, Toronto, ON, Canada; and Minette MacNeil, MEd, MScN, RN, , Toronto, ON, Canada

AIM: To evaluate feasibility of handheld skin tissue assessment device (the scanner) in preventing the incidence of pressure injuries (PIs) in the community hospital. METHODOLOGY: Phase 1: Conducted to control for Hawthorne effect. When standard protocol was used without regard to scanner reading, but implementation of standard protocol was reinforced by a person with a scanner. Device was used to scan all newly admitted patients on medical/stroke unit for the length of stay for 1 month. Standard intervention protocol was implemented, and no interventions were instituted according to scanner readings. Phase 2: (A) First 30 patients admitted to the ALC unit were scanned from admission up to 14 days, and interventions were implemented based on scanner reading and standard protocol. (B) First 100 newly admitted patients to the hospital were scanned from admission day to 3 days, and interventions were based on scanner reading and the standard protocol. Pressure ulcer development, scanner readings, standard assessment, and intervention (Braden Scale score–based protocol) were recorded using a data collection tool and analyzed. Data were compared to hospital historical and concurrent data. RESULTS: A total of 235 patients were scanned: Phase 1: 89 patients were scanned, and a 13.4% incidence was found. Phase 2: 146 patients were scanned, and a 1.3% incidence was found. Data suggest that intervention according to the scanner reading decreased incidence 10 times (90% reduction). CONCLUSIONS: Current practice misses opportunities for early detection and early intervention that can prevent PIs. It is based on risk assessment and visual assessment of skin in areas prone to PIs. When visually evident, significant tissue damage has already occurred and opportunity for prevention is already missed. In our pilot study, the scanner has been successfully used in practice to generate real-time insight to confirm early detection of tissue damage and to target interventions, leading to lower incidence, earlier recovery, and lower costs of care.

1. Lyder CH, Ayello AE. Pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:chap 12.

2. O'Brien G. Investigation of the Accuracy of Early Pressure Ulcer Damage Assessment Using SEM Measurement vs. Nurses' Visual Skin Assessment. Provaznicka, Czech Republic: EPUAP; 2015.

3. VanDenKerkhof EG, Friedberg E, Harrison MB. Prevalence and risk of pressure ulcers in acute care following implementation of practice guidelines: annual pressure ulcer prevalence census 1994-2008. J Healthc Qual. 2011;33:58–67

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



Raquel Felix, BSN, RN, CCRN, , and Aimee Skrtich, MSN, RN, CCRN, NE-BC, , ICU, Pittsburgh, PA

The purpose of this project was to decrease the amount of skin breakdown in patients with severe acute respiratory distress syndrome (ARDS) who received prone therapy. ARDS is characterized by acute diffuse inflammation throughout the lungs, which causes the alveoli to fill with fluid. Research suggests that prone therapy results in a 16% mortality rate compared to a 32.8% rate in patients remaining supine (Guerin et al, 2014). With a combination of decreased oxygen saturation, hemodynamic instability, malnutrition, utilization of deep sedation, chemical paralysis, and prone therapy, the patient is at high risk for developing skin breakdown. In prior practice, patients with severe ARDS received this treatment using automated prone therapy. Due to a combination of problems that included the amount of varying stages of skin breakdown from the use of automated prone positioning in the critical care units, manual prone positioning was implemented in attempts to remedy the issues associated with automated prone therapy. An education program was developed using a literature review of evidence-based practice pertinent to prone therapy, pressure ulcer prevention in patients with ARDS, and device-related pressure ulcer prevention. The program was used to train the critical care nurses of a large urban hospital how to safely prone the patient manually and prevent skin breakdown with the use of a preventative skin care bundle. This was done so by video instruction and demonstration during various skills trainings and critical care classes for new staff. This bundle includes a turning and repositioning schedule, use of appropriately placed pillows and foam dressings, and use of a preventative surface and skin care mattress. Skin breakdown is noted to have dramatically decreased in occurrence and severity since implementation of this preventative education program that is believed to be best practice in patients with severe ARDS.

Campbell N. Electronic SSKIN pathway: reducing device-related pressure ulcers. Br J Nurs. 2016;25(15):S14–S26.

Drahnak DM. Prone positioning of patients with acute respiratory distress syndrome. Crit Care Nurse. 2015;35(6):29–37. doi:10.4037/ccn2015753.

Girard R, Baboi L, Ayzac L, Richard J, Guérin C. The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning. Intensive Care Med. 2014;40(3):397–403. doi:10.1007/s00134-013-3188-1.

Guerin C, Baboi L, Richard JC. Mechanisms of the effects of prone positioning in acute respiratory distress syndrome. Intensive Care Med. 2014;40(11):1634–1642. doi:10.1007/s00134-014-3500-8.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Terrie Beeson, MSN, RN, CCRN, ACNS-BC, , and Audrey Glossenger, MSN, RN-BC, CCRN-K, , Indianapolis, IN

PROBLEM/PURPOSE: Hospital-acquired pressure injury (HAPI) continues to be a national problem for many hospitals. To enhance resources available to nurses, the Wound Treatment Associate (WTA) course was offered. The purpose of this evidence-based practice (EBP) project was to determine if the WTA peer developed skin educational fair enhanced confidence, knowledge, and HAPI rates. METHODS: A pre/postcomparative design was utilized for the EBP collaborative project. A group of clinical nurse specialists, educators, and WTA clinical nurses developed the content and curriculum of the skin fair using the EBP projects of the WTA nurses. A focus on skin and pressure injury prevention measures was determined as the overarching goal of the fair. The WTAs were empowered to create fun and relevant educational content for stations related to their projects using an eye-catching theme for the fair, “HAPI Days,” which was suggested by one of the WTA nurses. The content was structured into 4 stations: static air overlay usage, nasal tube taping and application of external fecal management device, completion of a Braden Scale score and discussion of patient-specific interventions, and review of 2016 NPUAP (National Pressure Ulcer Advisory Panel) staging guidelines with application to assessment and documentation of a wound. A pre/postsurvey related to nurse confidence and knowledge was collected. RESULTS: Leadership approved mandatory attendance of the fair that resulted in 378 nurses trained. The pre/postsurvey resulted in a 20% to 30% increase in knowledge of nasal tube taping and static overlay. Braden Scale score and staging confidence increase up to 40%. In addition, HAPI rates decreased from an average of 2.0 to 0 for the month of October. CONCLUSIONS/IMPLICATIONS: Engaging nurses in WTA training program and EBP projects enhanced knowledge transfer for nurses and improved patient outcomes.

Ostomy—Psychosocial and Quality-of-Life Aspects



Alexis Sherman, BSN, CWOCN, , Wound Ostomy Continence Nursing, New York, NY

A WOC nurse at an academic hospital in the Eastern United States was approached by a transplant surgeon regarding care for a complex fistula on a young patient in a third-world country with little resources. When provided with a photograph of this fistula, the WOC nurse was able to use a high-resolution printout of the fistula to provide step-by-step instructions translated into Spanish on how to manage fistula. The step-by-step guide along with donated supplies was sent to where patient was hospitalized and allowed for better containment of effluent and protection of skin until surgery to repair fistula could be performed. Photographs and telemedicine can be used as a way to manage complex fistulas in areas with limited resources and minimal caregiver knowledge.

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



Kathleen McLaughlin, DNP, RN, CWOCN, , Staff Development, Paoli, PA; Jennifer Delozier, BSN, RN, PCCN, CWOCN, , PCU, Paoli, PA; Cheryl Freese, RN, WTA, , ICU, Paoli, PA; Milana Sablich, BSN, RN, , Paoli Hospital, Paoli, PA; Mary McLaughlan, RN, , and Colleen Andrew, , telemetry/oncology, Paoli, PA; Kathryn Artzerounian, RN, CMSRN, ANCC, , ASU, Paoli, PA; Stacey Bradley, BSN, RN, WTA, , Emergency Department, Paoli, PA; Denise McKenna, RN, , OR, Paoli, PA; and Diane Schuster, BSN, RN, CPAN, , PACU, Paoli, PA

Cost containment and nursing care are 2 topics that are not frequently discussed together. Yet, the bedside nurse directly impacts many costs associated with patient care. The Dermal Defense Committee at a regional level II trauma center and the community hospital have adopted methods to integrate this topic into daily nursing practice. This team regularly engages in peer-to-peer education regarding skin and wound care issues, as well as monthly Prevalence and Incidence studies. These nurses and the patient care technician are employed in every inpatient hospital unit, as well as the emergency department, ambulatory surgical unit, operating room, and postanesthesia care unit. Rounding on patients during monthly prevalence studies, the members noticed the presence of unnecessary supplies in every room. These members then embarked on a cost containment project. The first step of which was to document the unnecessary items in each patient room, along with duplication of products. Photographs were taken and shared with each unit. The next step was identifying the cost of supplies. Members worked with supply chain management to ascertain this information. Team members educate staff on every unit on an almost daily basis regarding proper use of supplies. In order to reach staff on all shifts as well as weekend staff, a game, titled the “Price is Right,” was developed. Staff were given the opportunity to place prices next to commonly used patient care supplies (superabsorbent disposable incontinence pads, barrier creams, skin protectants, and perineal cleanser, etc). This game is recreated yearly during a 12-hour Dermal Defense Education Day. This simple strategy resulted in less clutter in patient rooms, ensuring the right products are used for each patient every time, and improvement in nosocomial pressure injury rates. This demonstrates that nurses can be fiscally responsible while delivering a “5 Star Patient Care” experience.

Brady DJ, Cornett E, DeLetter M. Cost reduction: what a staff nurse can do. Nurs Econ. 1998;16(5):273–276.

Jankowski IM, Nadzam DM. Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs. Jt Comm J Qual Patient Saf. 2011;37(6):253–264.

Padula WV, Mishra MK, Makic MBF, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4):385–392.

Palese A, Carniel G. The effects of a multi-intervention incontinence care program on clinical, economic, and environmental outcomes. J Wound Ostomy Continence Nurs. 2011;38(2):177–183.

Wound—Evidence-Based Interventions



Jane Ellen Barr, DNP, RN, CWON, , Nursing Administration, Seaford, NY; Kristin Lang, MSN, RN, , Wound, Ostomy, Continence, Hicksville, NY; Avital Friedman, BSN, RN, , Wound, Ostomy, Continence Service, Great Neck, NY; and Katharine Edwards, BSN, RN, CWOCN, , Wound, Ostomy, Continence Nursing Service, New Hyde Park, NY

An evidence-based program was initiated in a critical care service line to decrease the incidence of pressure injuries that were occurring in patients being proned. The ACE Star Model of Knowledge Transformation was used as the conceptual framework for the initiative. Although pressure injury rates were low in the critical care service units (0.8), 25% of pressure injuries that did occur were in proned patients. A root-cause analysis identified that skin care prevention measures were not standardized for proned patients. Literature review and analysis were done using Cochrane, PubMed, and CINAHL; clinical practice guidelines were also reviewed. Based on the evidence, a checklist was developed that identified specific protocols for preproning therapy and while patient was in both supine and prone positions. A pronation preparation kit was also developed so that staff would have all items on the checklist needed when initiating prone therapy. Education was provided to all staff prior to integration of the checklist into practice. Prepronation data revealed that 4 of 4 patients proned developed pressure injuries. Postintegration of the evidence-based practice changes resulted in prevention of proned patients developing pressure injuries: 3 patients were proned, with no patients developing pressure injuries. Standardizing skin prevention measures through utilization of a checklist approach to maintain skin integrity in critical care proned patients resulted in eliminating pressure injuries in this patient population.

Jackson M, Verano JX, Fry JE, Rodriquez AP, Russian C. Skin preparation process for the prevention of skin breakdown in patients who are intubated and treated with RotoProne. Respir Care. 2012;57(2):311–314.

Lopez MJ. Prone positioning in acute respiratory distress syndrome: a multicenter randomized clinical trial. Intensive Care Med. 2008;34:1487–1491.

Wound—Product Selection and Innovations



Thanuttha Tiensawang, MSN, CNS, GNP, CWOCN-AP, , Wound Ostomy Continence Nursing Service, Los Angeles, CA

PURPOSE: Management of large draining enterocutaneous fistula in a morbidly obese patient is a challenge. Goals include containing effluent, protecting and promoting granulation of tissue mesh, preventing infection, optimizing nutritional status, promoting ostomy self-care, and achieving wound closure with split-thickness skin grafting. Intubating the fistula and applying negative pressure wound therapy (NPWT) resulted in leakage of effluent from around the drain and contamination of biological mesh, increasing the risk for wound infection. OBJECTIVE: Use a collapsible fistula isolation device to contain fistula effluent while using NPWT with installation (NPWT-i) of normal saline to cleanse the wound, promote granulation over biological mesh, and prepare wound for split-thickness skin graft (STSG). OUTCOMES: A morbidly obese patient with grossly infected abdominal wall mesh with enterocutaneous fistula and giant recurrent ventral hernia underwent surgery for excision of infected mesh, exploratory laparotomy, lysis of adhesions, small bowel resection with primary anastomosis, excision of giant ventral hernia, and abdominal wall reconstruction with a 30 × 20-cm biological mesh. Her postoperative course was complicated by fluid collection and a colocutaneous fistula managed by intubating the fistula with a large drain and using NPWT to promote granulation over the biological mesh. The tube was removed due to leakage of fecal effluent 3 days after surgery, and moist saline dressings were applied to the wound. The patient was started on total parenteral nutrition. A collapsible fistula isolation device to divert fistula effluent to an ostomy pouch was applied over the stoma, and NPWT-i was used to irrigate the wound with normal saline and to promote granulation and wound contraction. Periodic sharp debridement was performed periodically. Dressing changes were performed 3 times per week. The patient was ambulatory and able to tolerate a regular diet. The fistula effluent was diverted through the device and contained in an ostomy pouch. The patient learned how to empty her ostomy pouch. The wound was closed with an STSG after 10 weeks of therapy.

DiSaverio S, Tarasconi A, Walczak DA, et al Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review. Langenbecks Arch Surg. 2016;401:1–13. doi:10.1007/s00423-015-1370-3.

Ostomy—Stomal/Peristomal Complications



Carole Bauer, MSN, RN, ANP-BC, OCN, CWOCN, , Chronic Disease Management, Troy, MI; and Sameena Syed, PT, PRPC, , and Sharon Angeline, PT, , Physical and Occupational Therapy, Macomb, MI

TOPIC: Peristomal hernia (PH) is a pervasive, costly, and distressing problem for persons living with permanent ostomies. Prevalence rates vary greatly, ranging from 20% to 78% of patients. Persons with PH experience difficulties with pouch adherence, leakage, increased use of supplies, and reduced quality of life. At times, it may be difficult to conceal the peristomal bulge, making it difficult to find properly fitting clothing. More severe problems such as bowel strangulation, perforation, and obstruction can be life threatening. Risk factors for developing PH include type of diversion, size of the opening in the abdominal rectus muscle, age, weakness of the abdominal wall musculature, excessive coughing or vomiting, steroid use, intra-abdominal tumor growth, emergency placement, smoking, and obesity. PH may not be completely preventable. Nevertheless, available research suggests that early introduction of a support garment and an appropriately focused exercise and proper body mechanics education program can help prevent development of a PH (North, 2014; Thompson & Trainor, 2005). In addition, research has made it clear that optimal outcomes with respect to improved quality of life and decreased prevalence of PH depend upon patient adherence to garment use, exercise, and proper body mechanics recommendations. OBJECTIVE: To develop an interdisciplinary hernia prevention pathway for persons undergoing permanent ostomy surgery. PURPOSE: To develop and implement a formalized multidisciplinary program to promote adherence to hernia prevention self-care practices and to decrease the prevalence of PH among patients undergoing permanent ostomy surgery for cancer or inflammatory bowel disease. This program, directed by a certified WOC nurse practitioner, includes risk screening, comprehensive education from a physical therapist specially trained in pelvic floor rehabilitation, and support garment recommendations. OUTCOME: Our interdisciplinary hernia prevention pathway demonstrates flow process, points of contact with the patient, and discipline-specific interactions expected at each point of contact.

Bland C. Nurse activity to prevent and support patients with a parastomal hernia. Gastrointest Nurs. 2015;13(10):16–24.

North J. Early intervention, parastomal hernia and quality of life: a research study. Br J Nurs. 2015;23(5):S14–S18.

Readding LA. Assessing support garments in the management of parastomal hernia. Gastrointest Nurs. 2014;12(4):32–42.

Thompson MJ, Trainor B. Incidence of parastomal hernia before and after a prevention programme. Gastrointest Nurs. 2005;3(2):23–27.

Wound, Ostomy and Continence Nurses Society. Peristomal Hernia: Best Practices for Clinicians. Mt Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2011.

Wound—Evidence-Based Interventions



Annette Gwilliam, BSN, RN, CWCN, ACHRN, , Provo, UT; Deb Critz, BSN, RN, ACHRN, , Des Moines, IA; and Richard “Gus” Gustavson, MPH, RN, CHRNC, CWCN, CHT, CRT, , Las Vegas, NV

The prevalence of diabetes (in the United States) increased from 0.93% in 1958 to 7.02% in 2014 and continues to rise. In 2014, 21.9 million people had diagnosed diabetes mellitus (DM), with only 1.6 million in 1958.1 This increase in DM creates a need for programs to screen patients who will likely have complications including cardiovascular disease, kidney failure, visual impairments, and lower extremity conditions including amputations.2 Problem wounds are increasing in prevalence, resulting in growing healthcare cost and utilization of resources; diabetic foot ulcers (DFUs) account for 60% of amputations.3 Through appropriate interventions, patients can improve their quality of life (QOL) and slow or stop the cycle of destruction. There are times that this includes referral for hyperbaric oxygen treatments (HBO2). Our purpose was to share clinical practice guidelines for DFUs as researched and recommended by the Undersea and Hyperbaric Medical Society. Included with this research is a very detailed algorithm that will guide the clinician through wound assessment, the environment of care, vascular evaluation, and referrals. • Wound assessment: It includes evaluation of debridement options, infection, wound bed preparation, and periwound environment. • Environment of care: Treatment of underlying infection, controlled blood sugars, nutrition, lab values, off-loading, and behavior modification to promote healing. • Testing and vascularization: Transcutaneous oximetry monitoring provides a direct, quantitative assessment of oxygen availability to the periwound skin and an indirect measurement of periwound microcirculatory blood flow.4 This can be a significant predictor of limb salvage. • Referral guidelines: Compromised DFUs that have been present for greater than 30 days, classified as Wagner 3 (or higher), or show signs of ischemia. Add HBO2 postoperatively to the standard of care to reduce the risk of major amputation and incomplete healing.3,4 As wound/hyperbaric nurses use these guidelines, DFUs can be treated appropriately and the rate of healing will increase, therefore improving QOL.

Centers for Disease Control and Prevention. Long-term trends in diabetes: April 2016. Published 2016.

Centers for Disease Control and Prevention. Diabetes home, national data. http:// Published 2016.

Hwang ET, Mansouri J, Murad MH, et al A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. Undersea Hyperb Med. 2015;42(3):205–247.

Weaver LK. Hyperbaric Oxygen Therapy Indications. 13th ed. Durham, NC: Undersea and Hyperbaric Medical Society; 2014.

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



Andrew Marxen, BAN, MBA, RN, CWON, CWS, , Doylestown, PA; and Sarah Jackson, MPharmSci, , and Christian Stephenson, BSc, , Research and Development, Knutsford, Cheshire, United Kingdom

TOPIC: Zinc oxide barriers are widely used to prevent and treat skin irritation due to moisture-associated skin damage (MASD). Traditional rub-on zinc oxide applications can be messy and require a thick layer in order to provide protection to the skin. In addition, a significant quantity of cream is often wasted in the tube itself and residual product remaining on gloves.

PURPOSE: To evaluate the total number of applications and product waste between different zinc oxide–containing barrier products. METHODS: Three zinc oxide barriers were evaluated including a 2-oz spray-on micronized zinc oxide spray in a bottle (ZO1) and 2 rub-on, 4-oz zinc oxide barrier pastes in tubes (ZO2, ZO3). Five clinicians were instructed to apply the test products as they would in clinical practice and according to the manufacturer's directions for use. Total applications were counted, and pre- and postapplication glove weights were recorded until perceived empty. Then, residual product was removed and weighed for residual waste. Clinicians rated ease of application of each product on a 1 to 10 scale (10 being the easiest). RESULTS: (WEIGHTS IN OUNCES): Average number of applications: ZO1 = 39 (range, 31-46); ZO2 = 14 (range, 7-21); ZO3 = 19 (range, 9-35). Average glove waste: ZO1 = 0; ZO2 = 0.31; ZO3 = 0.66. Residual product waste: ZO1 = 0.2; ZO2 = 0.9; ZO3 = 0.44. Total waste: ZO1 = 0.2; ZO2 = 1.22; ZO3 = 1.1. Ease-of-application rating average: ZO1 = 10/10; ZO2 = 5.3/10; ZO3 = 3.5/10. Cost-effectiveness varies based on the delivery and application methods. Spray-on product allowed greater than twice the applications than rub-on products. There was no glove waste with the spray-on product, whereas the rub-on products produced consistent waste volumes. CONCLUSION: Although this study is conducted in a simulated clinical environment, results indicate there are many factors that contribute to the cost-effectiveness of the zinc oxide barrier products. Total applications, ease of use, waste, effectiveness, and price are some of these factors.

Wound—Product Selection and Innovations



Patricia Turner, BSN, RN, CWS, CWOCN, , Nursing, Hopatcong, NJ

Recent 2016 National Pressure Ulcer Advisory Panel (NPUAP) changes to the pressure injury definition and to the staging definitions bring to the forefront the importance of accurate assessment and staging. Accuracy is important because of the clinical implications of inaccuracy and also because of the financial implications of various stages of facility-acquired pressure injuries to those facilities. The NPUAP staging system gives descriptive definitions for each stage of pressure injuries. It may be difficult to apply that theory to the application of practice in assessing and staging appropriately. This may be especially true with novice wound care clinicians. Adult learning styles are more visual in nature. Principles of adult learning include self-direction and internal motivation. Adults bring to the learning process experience and past knowledge. In addition to the information available through the NPUAP and the WOCN Society, finding an easy, simple reference and educational tool for in-servicing and reviewing the NPUAP pressure injury staging system can be challenging. Utilizing adult learning principles, an apple analogy was developed to help identify the various pressure injury stages and levels of tissue involvement. The “Apple P.I.E” (Pressure Injury Explanation) Staging Educational Tool gives comparisons and pictures for quick and easy evaluations. For example, a stage 4 pressure injury, which involves loss of epidermis and dermis, is present in the subcutaneous tissue, and involves underlying structure, is equated to an apple with a large bite out of it, showing the skin layers are gone; it is into the white part of the apple, and the apple's core, or structure, is involved. For all levels of staff, this analogy is a simple, effective way to teach the NPUAP staging definitions and can assist the WOC nurse or anyone responsible for educating on pressure injury staging. The “Apple P.I.E” concept was originally known as “Apples to Ulcers,” and its content is patent pending.

NPUAP 2016 Pressure Injury Staging definitions.

Ostomy—Psychosocial and Quality-of-Life Aspects



Heather Brigstock, MSN, RN, CNL, , Santa Rosa, CA

Hospital admissions are now shorter than ever, with the majority of new ostomy patients discharged to the home setting. Therefore, follow-up care and education are crucial. Unfortunately, many patients are unable to obtain this follow-up due to barriers such as lack of insurance reimbursement for home care and a lack of outpatient clinics equipped to provide care for ostomy patients. Follow-up care and quality of patient education can affect patient health confidence. Low patient health confidence has been found to correlate with higher complication and readmission rates. Conversely, peer-to-peer education has been shown to increase patient learning and self-efficacy. The literature has shown that ostomy patients have a desire to learn from a peer in addition to their certified nurse. In response to this desire, a community-based, peer-facilitated new ostomy patient workshop was implemented using both hands-on format and lecture to reinforce and build upon the patient education performed in the hospital. Patients were given the opportunity to ask the peer facilitator questions related to life with an ostomy, as well as given information about community resources for ostomates. The facilitator was a master's prepared nurse with 15 years of experience living with an ostomy. The workshop objective was to increase patient health confidence through increased education and support. Five patients, 2 caregivers, and 2 certified WOC nurses attended. The patient attendees were all more than 9 months postdischarge; therefore, health confidence could not be measured in newly discharged patients. However, attendee feedback strongly supported the value of the workshop, particularly the peer-to-peer format. Attendee feedback also expressed a desire to make the workshop a permanent community resource for ostomy patients.

Kjaergaard-Danielsen A, Elgaard-Soerensen E, Burcharth K, Rosenberg J. Learning to live with a permanent intestinal ostomy: impact on everyday life and educational needs. J Wound Ostomy Continence Nurs. 2013;40(4):407–412.

Petosa RL, Smith RH. Peer mentoring for health behavior change: a systematic review. Am J Health Educ. 2014;45:351–357.

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

Walker CA, Lachman VD. Gaps in the discharge process for patients with an ostomy: an ethical perspective. MedSurg Nurs. 2013;22(1):61–64.

Wasson J, Coleman EA. Health Confidence: a simple, essential measure for patient engagement and better practice. Fam Pract Manag. 2014;21(5):8–12.

Wound—Product Selection and Innovations



Hannah Grothues, MS, LVT, SRT, , Global Medical Sciences, San Antonio, TX; Leah Griffin, MS, , Biostatistics & Data Mgmt, San Antonio, TX; and Miguel Martinez, BS, , Post Acute Franchise, San Antonio, TX

The purpose of this user evaluation was to examine a new remote therapy monitoring (RTM) system that monitors patient therapy adherence. The RTM system transmits data through a proprietary remote monitoring system used in the home care setting and gathers therapy usage data, which are transmitted to a clinical care network. The team monitors patient therapy daily and contacts each patient when he or she falls below a therapy compliance threshold. Twenty-three patients were evaluated for all or part of length of therapy. Therapy usage was transmitted periodically. Nonadherent patients were defined as not receiving therapy for 16 hours in a day and were contacted by phone to discuss therapy usage. Patients and clinicians were surveyed to assess perceived value of RTM. Interactions between the clinical team and patients resulted in several findings: increased adherence levels for patients who were nonadherent with therapy, patient satisfaction/peace of mind, and clinician awareness. When nonadherent patients were successfully contacted, patients became adherent 81% of the time on the following day. Nineteen out of 22 patients (86%) maintained an average therapy use of 16 hours or more during the monitored 30 days of therapy. One patient was not included due to discontinuation of therapy before 24 hours. Of 12 patient surveys received, 12/12 patients (100%) reported that they would want RTM if they needed negative pressure wound therapy (NPWT) again; 9/12 patients (75%) found RTM provided peace of mind on their healing journey. Of 7 clinician surveys received, 7/7 clinicians (100%) agreed that earlier interaction through RTM may impact wound progression for patients who do not adhere to therapy usage. This evaluation is the first to examine the features of NPWT with RTM. Preliminary findings indicate increased adherence for nonadherent patients who were contacted, increased satisfaction, and confidence in providing care from a distance.



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

PURPOSE: Many clinicians use an algorithmic approach to the wound management of the patient with diabetes.1 After addressing vascular issues, wound bed preparation is key to outcomes. Often overlooked is a biofilm-based wound management, need for exogenous extracellular matrix deposition,2 use of adequate off-loading, and reduction of edema.3 OBJECTIVE: Use of an algorithm incorporating evidence-based practice can assist in achieving wound improvement in patients with lower extremity diabetic neuropathic wounds. METHODS: A standardized stepwise algorithmic approach in an outpatient setting was developed directed at meeting intermediate outcomes that address biofilm management with a bacterial binding agenta as an initial intervention, followed by exogenous matrix application.b Serial sharp debridement was performed as needed on a weekly basis. Total contact casting,c if a diabetic plantar ulcer was involved or edema management with compression strengths as dictated by skin perfusion pressures, addressed the local and peripheral wound environments. Repeated implementation with this standardized approach with providers from novice to expert experience in wound management occurred over several months. RESULTS: Providers across the continuum embraced the algorithm, as intermediate outcomes were positive in the majority of patients. Novice providers appreciated guidance in the management of difficult wounds. Staff nurses were able to articulate rationale for treatment to providers and patients alike. Increasing compliance with treatment regimens was observed when patients saw visible improvement in their wounds. CONCLUSION: Using an algorithm to address specific physiological alterations in the wound bed of the patient with a lower extremity wound in a stepwise fashion to address local wound bed dysfunction improves patient adherence and provider consistency in wound management.

aCutimed Sorbact, BSN Medical, Inc, Charlotte, North Carolina.

bCutimed Epiona, BSN Medical, Inc, Charlotte, North Carolina.

cCutimed Total Contact Cast, BSN Medical, Inc, Charlotte, North Carolina.

Kimmel H, Regler J. An evidenced-based approach to treating diabetic foot ulcerations in a veteran population. J Diabet Foot Complications. 2011;3(2):50–54.

Augustine R. Role of wound dressings in the management of acute and chronic diabetic wounds. http:// Accessed October 1, 2016.

Armstrong D, Isaac A, Belvilacqua NJ, Wu S. Offloading foot wounds in people with diabetes. Wounds. 2014;26(1):13–20.



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

PURPOSE/OBJECTIVE: Bioburden wound management is often accomplished using an antimicrobial agent. One of the most popular agents, silver is available in several chemical and physical forms—each of which affects biocidal and biofilm disruption activities. Fibrous silver oxysalt dressings (FSODs) have demonstrated decreased bioburden via lower bioburden assessment tool scores1 and wound surface area reductions in unblinded case series1,2 reports. It is unknown how, if at all, FSODs impact inflammation. METHOD: Ten certified wound nurses (CWNs), blinded to the topical agent used, evaluate standard and wound thermography serial photographs of wounds with different etiologies receiving an FSODa over a 2-week period. Bioburden is determined using the visual Bioburden Assessment Tool.3 Wound thermography evaluations, a direct measure of wound bed and periwound inflammation,4 are done concurrently. RESULTS: CWNs are able to objectively determine responses to an FSOD application in a variety of wounds using wound thermography and standard wound photos using a bioburden assessment tool. CONCLUSION: FSODs can impact bioburden, wound bed, and periwound inflammation when applied over a 2-week period. Use of objective measurements, such as wound thermography in conjunction with completion of a bioburden scale, can be beneficial to guide topical wound treatment. Further study is warranted.

aKerraContact™Ag, Crawford Healthcare, Ltd, Doylestown, Pennsylvania.

1. Bakeer M, Vair A, Keast D. Evaluation of silver-impregnated dressings in a clinical setting: observations on efficacy and practicality. Presented at: Edmonton West Primary Care Network, May 2015; Edmonton, AB, Canada.

2. Motta G, Merkle D, Milne C, Saucier D. A multi-center prospective clinical evaluation and cost comparison of a new silver oxysalts dressing. Presented at: Wound, Ostomy and Continence Nurses Society 44th Annual Conference; June 9-13, 2012; Charlotte, North Carolina.

3. International Consensus. Appropriate Use of Silver Dressings in Wounds. London, England: Wounds International; 2012.

4. Dini V, Salvo P, Janowska A, Di Francesco F, Barbini A, Romanelli M. Correlation between wound temperature obtained with an infrared camera and clinical wound bed score in venous leg ulcers. Wounds. 2015;27(10):274–278.

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



Radoslava Stoddard, BSN, RN, CWON, CFCN, , Nursing Administration, St Louis, MO

INTRODUCTION: Certified WOC nurses (CWOCNs) are integral to the hospital wound and ostomy formulary. When a new product is added, who becomes the gatekeeper and can we influence new product decisions? Evaluation of evidence-based products falls in our domain, and navigating supply chain value analysis by teams can be daunting. PROBLEM: Our facility was using a 40% zinc oxide paste to manage moisture-associated skin damage (MASD), specifically incontinence-associated dermatitis (IAD). This required a provider's order, dispensing from Pharmacy, and a licensed nurse to apply. These requirements delayed treatment for IAD and limited our unlicensed patient care technicians (PCTs) from providing complete incontinence care, including application of the zinc oxide paste. PROPOSED SOLUTION: Evaluation of a spray-on 25% zinc oxide/20% dimethicone (SOZO) to replace the 40% zinc oxide paste, have it dispensed through central supply, and write a Clinical Practice Guideline for use by nurses and PCTs to expedite IAD management. RESULTS: Clinical staff and PCTs validated SOZO and reported clinical effectiveness and easier application with reduced cost. However, during approval and implementation of the product, Pharmacy intervened and declared the product as an “over-the-counter medication,” requiring the same pharmacy dispensing that we were trying to eliminate to improve care delivery processes. Under the FDA Code of Federal Regulations, the “Skin Protectant Monograph”1 (SPM) states that products with zinc oxide ingredient of 1% to 25% and dimethicone 1% to 30% can be labeled as a skin protectant. We found many other products stocked on the floor and distributed through Central Supply including a 6% dimethicone cream and a 43% petrolatum barrier. Since they are regulated by the same SPM, there was no credible argument to limit SOZO's use through pharmacy. CONCLUSION: As advocates of effective and efficient care, our facility now benefits from SOZO stocked in Central Supply for immediate use. Yes, CWOCNs can influence product placement.

1. Food and Drug Administration. Electronic Code of Federal Regulations, Title 21, Volume 5. http://

Continence—Evidence-Based Treatment and Management



Kersten Reider, BSN, RN, CWOCN, , Elizabeth McElroy, CRNP, CWS, CWOCN, , and Stormy Lemay, WOCN, , West Reading, PA

Patients in the intensive care unit (ICU) are at particular risk of skin breakdown. Since the skin is the primary line of defense against mechanical forces, chemicals, and pathogens, it is vital that it is well protected. Particularly in patients with incontinence, the skin is exposed to urine and stool, which contain caustic elements that deteriorate the integrity of the skin. Once skin integrity is compromised, it is more susceptible to breakdown and outside elements. The purpose of this quality improvement project was to evaluate a cyanoacrylate skin protectant for the protection of sacral skin in incontinent ICU patients. For this process improvement project, 30 ICU patients with fecal incontinence were selected for evaluation. Standard skin care and pressure ulcer prevention protocols were maintained for all patients. The skin was evaluated for breakdown daily. The number of applications and ampules used was also recorded. All skin injuries were evaluated, including moisture-associated skin damage, pressure injuries, and shearing injuries. Overall, the cyanoacrylate skin protectant helped maintain the integrity of the at-risk skin and skin breakdown was limited. This is a beneficial option for ICU patients with fecal incontinence to prevent breakdown since a sacral foam–bordered dressing cannot be maintained in patients with fecal incontinence.

Woo KY. Health economic benefits of cyanoacrylate skin protectants in the management of superficial skin lesions. Int Wound J. 2014;11(4):431–437.

Woo KY, Chakravarthy D. A laboratory comparison between two liquid skin barrier products. Int Wound J. 2014;1(5):561–566.

Rawlings AV, Harding CR. Moisturization and skin barrier function. Dermatol Ther. 2004;17(suppl 1):43–48.

Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient. J Wound Ostomy Continence Nurs. 2016;43(3):235–241.

Wound—Dermatological Management/Issues



Pam Achabal, MSN, RN, CWON, , Spokane, WA; Dalilah Baugh, BSN, RN, CWOCN, , Ruth Bryant, PhD, RN, CWOCN, , and Robin Knaff-Baker, BSN, RN, CWON, , Wound and Ostomy, Spokane, WA; Michelle Best, BSN, RN, CWOCN, , Teresa Patterson, BSN, RN, CWON, CFCN, , Rebecca Thomas, BSN, RN, CWOCN, , and Elizabeth Wrigley, BSN, RN, CWON, CFCN, , Wound and Ostomy, SPOKANE, WA; and Morgan Pitschka, BSN, RN, CWOCN, CFCN, , Wound and Ostomy, Post Falls, ID

Lesions that involve the perirectal, perianal, and/or fleshy buttocks are often misdiagnosed as moisture-associated skin damage (MASD) or incontinence-associated dermatitis (IAD) or pressure ulcers. However, a viral etiology of herpes zoster (shingles) should also be included in the differential. When a viral etiology is overlooked, appropriate treatment is delayed and the patient is subjected to prolonged pain, suffering, and additional complications. Furthermore, because hospital-acquired pressure ulcers are closely monitored by local and state regulatory agencies, misdiagnosis of viral lesions as hospital-acquired pressure ulcers reflects negatively on the health care organization, casting doubt on quality of care and adversely impacting reimbursement. While early primary manifestations of zoster lesions are distinctive and more easily recognized, manifestations of the condition in later phases can be misleading. Vesicles are often replaced with ulcerations, and erythema or maceration in the perianal or buttocks area may or may not be present. In isolation, these physical assessments often lead to an incorrect diagnosis such as MASD, IAD, or pressure ulcers. Subjective assessments (ie, pain) and medical history (ie, age, stress, chronicity of illness, immunosuppression) are a significant source of data for discerning the correct etiology. This presentation presents a holistic discriminating approach that incorporates patient factors, nursing factors, and environment factors to facilitate a prompt and accurate method of identifying and managing perianal and buttocks lesions of viral etiology.

Ostomy—Product Selection and Innovations



Darcy Helder, BSBA, , Minneapolis, MN; and Mary O'Day, RN, CWON, , Wound Ostomy Nursing Department, Minneapolis, MN

PURPOSE: To measure the system impact on patient experience by improving the ostomy products offered. We aimed to make things easier for staff, reduce complications with patients, and see if this process of standardization could impact overall patient satisfaction scores. The system also identified multiple manufacturers of ostomy products and expressed a desire to eliminate keeping so many items in the system. Supply cost savings to the system was also a goal of the standardization project. METHODS: A wound/ostomy fair was held with multiple manufacturers to present to the committee members. Three companies were chosen for the ostomy trials at 3 of the hospitals. Another consideration for improvement was the transition of care from patient to home. Collaboration between the acute and home care WOC nurses was initiated to discuss improvement. RESULTS: One manufacturer was chosen for the standardized formulary. Items in the system went from 76 down to 32, although the core formulary for all floors/staff nurses is only 8 items. Preoperative teaching kits were standardized to the American College of Surgeons Home skills kit and a folder from the hospital system. In prior research, patients who did not use the kits were twice as likely to visit the emergency department in the 2 weeks after their operation.1 Further, the contract provided the system cost savings of 17%. CONCLUSION: Patient experience scores were raised, specifically for patients undergoing ostomy surgery, from 5th percentile in 2014 to the almost the 30th percentile in 2015.

1. Heneghan KC, McGee MF, Bailey HR, Sachdeva AK, Daly JM, Davis E, Colwell JC. 2015. Ostomy Home Skills Kit (OSHK) is Effective at Preparing Patients to Confidently Manage Their Post-Operative Recovery. Journal of Cancer Education. 2015;30(3):S320–21.

Professional Practice—Implementing a Pressure Ulcer Prevention Program



Patricia Blaschak, RN, CWOCN, , Rehabilitation, Las Vegas, NV; and Rosemary Thuet, MSN, RN-BC, NE-BC, , Education, Las Vegas, NV

PURPOSE: Reduction of hospital-acquired pressure injuries (HAPIs) and correction of practice deficits regarding prevention of pressure injuries. The WOC nurse was notified of all HAPIs starting in November 2013. 2014 prevalence study showed an HAPI rate of 6.5%. Upon investigation, high-risk patients were not receiving evidence-based nursing interventions, and there was not a formal pressure injury prevention program in place. There was a knowledge deficit regarding the relationship of low Braden subscale scores and specific nursing interventions. High-risk patients were on regular foam mattresses. Operating room (OR)-acquired pressure injuries were increasing. OR table pads were thin, vinyl-covered foam and were 16 years old. Shearing forces injured deep tissues. OBJECTIVE: To create a multidisciplinary team to correct knowledge, practice, and equipment deficits and the creation of a comprehensive Pressure Injury Prevention Program. SUMMARY: HAPIs called for a hospital-wide campaign to correct deficits and change our culture from treatment only to prevention of pressure injuries. RESULTS: Staff attended the PUPS training in September 2015. New 4-in OR pads, air beds, seating cushions, heel lifts, and 5-layer foam prevention dressings were purchased. Educational resource materials were distributed to all units. HAPIs decreased from 6.5% in 2014 to 1.2% in 2016. Exclusion of stage 1 pressure injuries resulted in 0% HAPIs for 2016. The American Journal of Surgery estimates the cost of healing a stage 4 pressure injury to be about $129,000.00 (Brem et al, 2010). Eight of the 20 HAPIs from 2014 were deep tissue injuries, which can open to stage 4 injuries even with optimal care. Estimated cost savings preventing these injuries is $1,032,000.00.

Baranoski S, Ayello E. Wound Care Essentials Practice Principles. 2004:253–254.

Brem H, Maggi D, Nierman D, et al High cost of stage IV pressure ulcers. Am J Surg. 2010;200(4):473–477. doi:10.1016/j.amjsurg.2009.12.021.

Byrne J. Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients. Am J Crit Care. 2016;25(3):228–234. doi:10.4037/ajcc2016979.

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

Preventing pressure ulcers in hospitals. Agency for Healthcare Research and Quality. Published 2016.


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



Joy Pittman, PhD, ANP-BC, FNP-BC, CWOCN, , Wound Ostomy Continence, Indianapolis, IN; and Judith Mosier, MS, MSN, RN, CWOCN, , Wound Ostomy Continence Team Methodist, Indianapolis, IN

With increasing demands to improve efficiencies, promote quality care, and prevent pressure ulcers, direct care pressure injury prevention (PIP) expertise is necessary. The Wound Treatment Associate (WTA) program was identified as one method to build unit-level expertise and to enhance PIP strategies. The purpose of this project was to enhance nursing involvement in PIP initiatives, augment unit-level PIP evidence-based practice (EBP), and decrease hospital-acquired pressure injury (HAPI) rates. The WTA program was offered to nurses across a large Midwestern healthcare organization and the community. Following completion of the WTA program, nurses were encouraged to develop an EBP project. One hundred forty-five nurses participated in the WTA program from acute care, long-term acute care, and skilled nursing facilities across Indiana in 2013-2016. Specifically, 100 nurses from 9 facilities participated with a 100% passing rate. Four WTA EBP projects were implemented and presented at the organization's 2014 research conference. Ten WTA EBP projects were implemented in 2016. Eight of the WTA graduates pursued WOC education to become certified WOC nurses. HAPI rates decreased from 2.8% (2013) to 1.8% (2014) (P = .006), with continued decline to 1.15%. There were 30 fewer HAPIs per year and a 54% reduction in device-related injury. State reportable events reduced from 3 (2012) to 0 (2013) events, and 1 (2014) event with a potential savings of $140,000. However, in 2015, with an increase in nursing turnover, novice nurses, and organization restructuring, sustaining HAPI improvement has been challenging. With the initiation of a second WTA cohort, 2016 HAPI rates have begun to decline, with a mean rate of 1.51% and no state reportable pressure ulcers to date. The WTA program demonstrated positive results through engaging direct care nurse involvement in PIP initiatives, increasing PIP EBP initiatives at unit level, and decreasing HAPI rates.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. In:Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

National Pressure Ulcer Advisory Panel. World Wide Pressure Ulcer Prevention Day http:// Published 2015. Accessed September 19, 2016.

Wound—Preventative Practices New



Shandra Averett, BSN, RN, , and Katie Schmidt, BSN, RN, , Boston, MA

Nosocomial pressure ulcer incidence continues to be a significant problem in acute and long-term care facilities, and many studies have tested interventions to reduce the incidence of facility-acquired pressure injury with mixed success. The theory of planned behavior may provide some insight into nursing attitudes and barriers to discover why individualized pressure ulcer prevention interventions are not completed despite having evidence-based, facility-provided pressure ulcer prevention protocols that nurses are expected to follow. However, no American studies have been completed asking bedside nurses the reasons they believe that pressure injury occurs and prevention practices are not consistently maintained. In a cross-sectional study, a survey was given to long-term care facility bedside nurses and certified nursing assistants. Their reasons for incomplete pressure ulcer prevention assessment were time, other patient care priorities, and staffing insufficiency. Nurses stated that time, patient noncompliance, and staffing issues lead to interventions being incomplete. Time, other patient priorities, and staffing issues were the staff's barriers to documentation of prevention practices. Nurses who had formal training on pressure ulcer prevention protocols and practices felt comfortable performing the preventative interventions. Lack of trust or will to perform the prevention protocols was not the reason pressure ulcer prevention interventions were not followed.

Ackerman C. “Not on my watch”: treating and preventing pressure ulcers. Medsurg Nurs. 2011;20(2):86–93.

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Anderson M, Guthrie P, Kraft W, Reicks P, Skay C, Beal A. Universal pressure ulcer bundle with WOC nurse support. J Wound Ostomy Continence Nurs. 2015;42(3):217–225.

Armor-Burton T, Fields W, Outlaw L, Deleon E. Healthy skin project: changing nursing practice to prevent and treat hospital-acquired pressure ulcers. Crit Care Nurse. 2013;33(3):32–39.

Asimus M, MacLellan L, Li P. Pressure ulcer prevention in Australia: the role of the nurse practitioner in changing practice and saving lives. Int Wound J. 2011;8(5):508–513.

Beeckman D, Clays E, Van Hecke A, Vanderwee K, Schoonhoven L, Verhaeghe S. A multi-faceted tailored strategy to implement an electronic clinical decision support system for pressure ulcer prevention in nursing homes: a two-armed randomized controlled trial. Int J Nurs Stud. 2013;50: 475–486.

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Bry K, Duescher D, Sandrick M. Never say never: a descriptive study of hospital-acquired pressure ulcers in a hospital setting. J Wound Ostomy Continence Nurs. 2012;39(3):278–281.

Centers for Disease Control and Prevention. http:// Published 2016. Accessed March 28, 2016.

Chaboyer W, Gillespie B. Understanding nurses' view on a pressure ulcer prevention care bundle: a first step towards successful implementation. J Clin Nurs. 2014;23:3415–3423.

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Cox J, Roche S, Gandhi N. Critical care physicians: attitudes, beliefs and knowledge about pressure ulcers. Wound Care J. 2012;26(4):168–176.

Creehan S, Cuddigan J, Gonzales D, et al The VCU Pressure Ulcer Summit—developing centers of pressure ulcer prevention excellence: a framework for sustainability. J Wound Ostomy Continence Nurs. 2013;43(2):121–128.

Dellefield M, Magnabosco J. Pressure ulcer prevention in nursing homes: nurse descriptions of individual and organizational level factors. Geriatr Nurs. 2014;35:97–104.

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Gill C, Moore Z, Ain I. An exploration of fourth-year undergraduate nurses' knowledge of and attitudes toward pressure ulcer prevention. J Wound Care. 2013;22(11):618–622, passim.

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Horn S, Bender S, Bergstrom N, et al Description of the National Pressure Ulcer Long-Term Care Study. J Am Geriatr Soc. 2002;50:1816–1825.

Kallman U, Suserud B. Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment—a survey in a Swedish healthcare setting. Scand J Caring Sci. 2009;23(2):334–341.

Lyder C, Wang Y, Metersky M, et al Hospital-acquired pressure ulcers: results from the National Medicare Patent Safety Monitoring System Study. J Am Geriatr Soc. 2012;60(9):1603–1608.

Levine J, Ayello E, Zulkowski K, Fogel J. Pressure ulcer knowledge in medical resident: an opportunity for improvement. Wound Care J. 2012;25(3):115–117.

Lewin G, Carville K, Newall N, Phillipson M, Smith J, Prentice J. Determining the effectiveness of implementing the AWMA guidelines for the prediction and prevention of pressure ulcers, in Silver Chain—a large home care agency. Stage 1: baseline measurement. Prim Intention. 2003;11(2):57–72.

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Ann N. Tescher, PhD, APRN, CCRN, CCNS, CWCN, , Mayo Clinic Rochester, St Marys Campus, Rochester, MN; Kathleen Berns, MS, APRN, CNS, CFRN, , and Lucas Myers, BA, , Mayo Medical Transport, Rochester, MN; Evan Call, MS, , Washington, DC; Patrick Koehler, BS, RRT, RPFT, , and Kip Salzwedel, AS, RRT, , Respiratory Care, Rochester, MN; Heather McCormack, DScPT, PT, CWS, , Physical Medicine and Rehabilitation, Rochester, MN; Christine Lohse, MS, , and Jay Mandrekar, PhD, , Biomedical Statistics and Informatics, Rochester, MN; and Marianne Russon, BS, , and Josh Burton, BS, , Centerville, UT

PURPOSE: To examine effectiveness of a commercial antishear mattress overlay (ASMO) in reducing shear and pressure and to increase comfort on an ambulance stretcher. METHODS: Randomized trial, crossover design. Thirty healthy adult volunteers in 3 body mass index (BMI) categories (blinded to the intervention) served as their own controls. The ASMO was randomly placed on a standard ambulance stretcher. PREDIA shear/pressure sensors were applied to the sacrum, ischial tuberosity (IT), and heel. The stretcher was placed in sequential 0°, 15°, and 30° elevations. The ambulance traveled over a closed course achieving a maximum of 30 mph, with 5 complete stops at each head-of-bed elevation for a total of 900 trials. Subjects rated discomfort on a 0 to 10 scale after each series of 5 runs. RESULTS: The peak shear difference between surfaces was −0.89, indicating that after adjusting for elevation, sensor location, BMI, type of ambulance, and driver, starting pause peak shear levels were 0.89 N lower for the ASMO compared with standard surface (P = .057). Compared with 0°, elevations of 15° and 30° increased these levels by 2.41 (P < .001) and 3.44 (P < .001) N, respectively. Compared with sacrum, IT and heel increased prerun shear levels by 2.54 (P < .001) and 1.01 (P = .079) N, respectively. The peak pressure difference between surfaces was −1.69, indicating prerun peak pressure levels were 1.69 mm Hg lower for the ASMO compared with standard surface (P = .070). Discomfort was lower on the ASMO than on standard surface at 0° and 30° (P = .004 and P = .014, respectively). Both surfaces had increased discomfort moving from 0° to 30° (P = .005 and P = .039, respectively). Differences in discomfort and shear between the 2 surfaces were not associated with BMI. CONCLUSION: For all measurements studied, the ASMO reduced levels of shear and pressure, although these differences did not reach statistical significance. Discomfort was reduced on the ASMO. Further study is indicated for medical transport.

Call E. Human and bench methods for measurement of shear and performance characteristics of devices intended to mitigate shear. Paper presented at: British Healthcare Trades Association “Shear and Tissue Integrity—The State of the Science”; 2014; Royal Overseas League, London, England.

Loerakker S, Manders E, Strijkers GJ, et al The effects of deformation, ischemia, and reperfusion on the development of muscle damage during prolonged loading. J Appl Physiol. 2011;111(4):1168–1177. doi:10.1152/japplphysiol.00389.2011.

Mimura M, Ohura T, Takahashi M, Kajiwara R, Ohura N. Mechanism leading to the development of pressure ulcers based on shear force and pressures during a bed operation: influence of body types, body positions, and knee positions. Wound Repair Regen. 2009;17(6):789–796. doi:10.1111/j.1524-475X.2009.00540.x.

Oomens C, Bader D. The role of shear forces and shear strains in the development of pressure ulcers. Paper presented at: British Healthcare Trades Association Shear and Tissue Integrity—The State of the Science; 2014; Royal Overseas League, London, England.

Ostomy—Psychosocial and Quality-of-Life Aspects



Kyle Merandy, DNP, ANP-BC, , Urology, New York, NY

BACKGROUND/PURPOSE: Bladder (urothelial) cancer patients undergoing urinary diversion (UD) experience significant changes that require important adjustments in their daily lives. This review identifies important factors that influence adaptation to life after cystectomy with the creation of a UD. METHODS: An integrative review was conducted through a review of primary research articles published between 1990 and 2014 using the PubMed and CINAHL Plus electronic databases. RESULTS: Findings were organized into 5 categories: (1) individual and family factors, (2) technical aspects related to the individual's ability to care for his or her UD, (3) perioperative nursing care, (4) educational needs, and (5) symptom experience. Individual and family factors: Family appears to play a major role in adaptation; many times they are relied on by the patient for assistance with management of the UD. Technical aspects related to the individual's ability to care for his or her UD: Instruction is needed on the use of UD-related appliances, irrigation equipment, catheters, and solutions. Perioperative nursing care: Nurses play a pivotal role in site marking, perioperative education, counseling, and teaching. Wound ostomy nurses add an additional layer of expert support. Educational needs: Appropriate educational materials are needed; patients desire and seek out information related to their UD. Symptom experience: Necessary to review expectations regarding postoperative symptom experience. CONCLUSION: This integrative review identified multiple factors related to adaptation to reconstructed urinary system in bladder cancer survivors treated with cystectomy with a UD. Findings provide a foundation for future research and interventions.

Merandy K. Factors related to adaptation to cystectomy with urinary diversion: an integrative review. J Wound Ostomy Continence Nurs. 2016;43(5):499–508. doi:10.1097/WON.0000000000000269.

Wound—Preventative Practices New



Barbara Pieper, PhD, RN, ACNS-BC, CWOCN, FAAN, , Janean Monahan, PhD, RN, , and Julia Farner, DNPc, BSN, RN, HHP, , Detroit, MI; and Mary Kathryn Keves-Foster, MSN, RN, , Dalia Alhasanat, BSN, RN, , and Maha Albdour, RN, APHN-BC, , College of Nursing, Detroit, MI

PURPOSE: Nursing care plans provide direction for the nursing team to individualize care and help patients meet their health goals. The purpose of this project was to examine what beginning nursing students included in a care plan assignment when a patient had an acute or chronic wound. METHODOLOGY: This quality improvement project was conducted by a faculty team using a cross-sectional, descriptive design. Data were collected from students' nursing care plans and analyzed in terms of wound assessment, nursing diagnoses, and interventions. Students recorded their assessment data using Gordon's Functional Patterns and identified the patients' priority nursing diagnoses using the North American Nursing Diagnosis Association (NANDA) terminology. STATISTICS: Data were analyzed with descriptive statistics. RESULTS: For the 80 care plans collected, 38 (47.5%) were about a patient who had a wound. Patients included 23 men (60.5%); 28 (73.68%) were African American. They had a mean age of 60.11 years (SD = 14.17 years). Twenty-five patients (65.8%) had surgical incisions; 4 (10.5%) had pressure ulcers/injuries; and 7 (18.4%) had other wounds (ie, stab, laceration, burn, etc). None of the students' assessments provided a detailed wound description. The most common wound descriptions were location (n = 19) and drainage (n = 15). For 8 patients (21.1%), students stated the wound was covered by a dressing, usually gauze (n = 3). Thirty nursing diagnoses were listed; the most common were impaired physical mobility or activity intolerance (n = 17), impaired comfort (n = 14), impaired skin integrity (n = 13), imbalanced nutrition (n = 7), and risk for infection (n = 6). Students sometimes mentioned the wound (n = 20) in their nursing impressions, usually the need to teach about the wound. CONCLUSIONS: Nursing students had beginning skills in assessment and writing nursing care plans for patients with an acute or chronic wound. Wound descriptions lacked depth of discernment. WOC nurses may help students understand wounds and their care by offering varied educational programs.

Wound—Psychosocial and Quality-of-Life Aspects



Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN, , and Katharine Sickon, Student, , Detroit, MI

PURPOSE: Affecting about 3.2 million people in the United States, hepatitis C is the primary cause of chronic liver disease and a global health challenge. Hepatitis C can affect the functioning of the liver, the health of the person, and thus wound healing. Baby boomers are 5 times more likely to have hepatitis C than other adults. As aging adults, they are also at risk for or have wounds. The purpose of this project was to examine (a) the occurrence of hepatitis C in high-risk patients seeking wound care and (b) their knowledge of it. METHODOLOGY: This quality project used a cross-sectional, descriptive design. The questionnaire included demographic and health information, hepatitis C history, and a 22-item true-false-don't know hepatitis C knowledge test. From June to September 2016, patients who were seeking wound care at an urban clinic and able to understand and respond were read the instrument. The questionnaire took 5 to 10 minutes to complete. STATISTICS: Descriptive and inferential statistics were used. RESULTS: Data were obtained from 58 patients (mean age = 61.07 years; 41 men; 51 were African American, and 38 were persons who injected drugs). Thirty-nine (67.2%) had been tested for hepatitis C; 31 were told they were hepatitis C+; 61.3% were sent to a specialty clinic for further care. The mean number correct on the hepatitis C knowledge test was 14.4 (SD = 5.7; range, 0-22); the mean percentage correct grade was 67.4% (SD = 25.9%). Patients who stated they had hepatitis C (M = 17.6) had significantly higher knowledge scores than those who did not know or were negative (M = 11.6), t56 = 4.66, P < .001. CONCLUSIONS: Patients at high risk for hepatitis C and seeking wound care may have been missed in terms of hepatitis C testing and referral for care. Hepatitis C knowledge was low. As a major public health problem, wound care practitioners can ask patients about hepatitis C, encourage hepatitis C testing and care, and provide hepatitis C information.

Wound—Preventative Practices New



Timothy Larsen, DNP, RN, APRN, CWOCN, , Connected Care, Independence, OH; and Mary Beth Zeni, ScD, RN, , Graduate Nursing, Pepper Pike, OH

In a large medical center in Northeast Ohio, the Medical Care at Home division has a Mobile Wound Provider Program since 2013. Program providers include a medical director, 2 advanced practice registered nurse certified wound ostomy continence nurses (APRN CWOCNs), and a home care team of WOC nurses. The purpose of this study was to evaluate the effectiveness of interventions provided by the APRN CWOCNs within the home care setting on patient outcomes. APRN interventions included evaluating and assessing wounds; prescribing treatments, therapies, and medications; ordering home care and other services; performing conservative sharp wound debridement of wounds; and ordering supplies and other medical equipment. Dependent variable was changes in wound measurements. METHODOLOGY: A retrospective study was conducted with 25 patients over a 90-day period who received at least 2 home visits by the APRN. Descriptive data included wound locations, type of wounds, comorbidities, prescribed medications, debridements, and total number of APRN visits. Per- and postintervention wound measurements were compared. RESULTS: Visits per patient ranged between 2 and 7, with a total of 79 visits. Wounds ranged from 1 to 5 per patient. Significant changes were found in pre- and postintervention wound measurements with X22 = 8.0, P < .05. Fifty-six percent of wounds healed, 24% remained the same, and 20% did not heal. CONCLUSION: The Mobile Wound Provider Program practices a comprehensive care model. The use of APRN CWOCNs was justified. APRNs worked closely with home care colleagues to ensure consistent patient care. Patients are seen in the outpatient setting (nursing homes, long-term care facilities, assisted living facilities, private homes, and hospice), and APRNs provide a consultative service for other home care agencies. APRNs can bill independently. The program continues to grow and flourish.

Wound—Nutritional Issues in Wound Healing



Amit Kumar Bhagat, , and Abhijit Chandra, , Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India; Mukesh Kumar Dwivedi, , and Rajeshwar Nath Srivastava, , Department of Orthopaedic Surgery, King George's Medical University, Lucknow, UP, India; and Saloni Raj, , Bengaluru, Karnataka, India

INTRODUCTION: Matrix metalloproteinases (MMPs) play a major role in wound healing: they can degrade all components of the extracellular matrix. In pressure ulcers, there is an excess of MMPs and a decrease of the tissue inhibitors of MMPs (TIMPs). This imbalance is probably one cause of impaired healing. This study was planned to evaluate the levels of MMPs at different follow-ups. MATERIAL & METHODS: Twenty-two subjects with pressure ulcers were enrolled in the study. Wound tissue was collected regularly during the 9-week follow-up period for the measurement of MMP-8, MMP-9, and TIMP-1. Results were analyzed by the degree of wound healing: good healers (defined by a reduction of 65% wound surface area at 5 weeks) and bad healers (reduction of <65% in wound surface area at 5 weeks). Levels of MMPs were analyzed by ELISA. RESULTS: Levels of MMP-8 and MMP-9 decreased earlier in the good healer group. The initial levels of MMP-8 were similar in good and poor healers (P = .1), but the level increased significantly at week 2 in good healers (P = .03). This was continued in successive weeks. There was a significant correlation between a high ratio of MMP-8/TIMP-1 and good healing (r = 0.65, P = .008). Pearson correlation analysis showed that an MMP-8/TIMP-1 ratio of 0.39 best predicted wound healing (sensitivity = 71%, specificity = 87.5%). CONCLUSION: A low level of MMP-8 seems essential to wound healing, while an excess of MMP-8 and MMP-9 is deleterious and could be a target for new topical treatments. The MMP-8/TIMP-1 ratio is a predictor of healing in pressure ulcers.

Gibson D, Cullen B, Legerstee R, Harding KG, Schultz G. MMPs made easy. Wounds Int. 2009;1(1):1–6.

Agren MS, Mirastschijski U, Karlsmark T, Saarialho-Kere UK. Topical synthetic inhibitor of matrix metalloproteinases delays epidermal regeneration of human wounds. Exp Dermatol. 2001;10:337–348.

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

The purpose of this study was to investigate facility-acquired pressure injuries (FAPIs) in 2 community hospitals from 2009 to 2016. Pressure injuries (PrIs) are a major health care issue in the United States, impacting approximately 3 million adults annually. FAPI incidence rates range from 0% to 53.4%. Approximately 15% of elderly patients develop a PrI in the first week of hospitalization. US FAPI treatment costs range between $37,800 and $70,000 per ulcer. Engaging nurses in prevalence studies facilitates commitment and ownership and empowers nurses to “champion” quality cost-effective care in preventing FAPIs. After institutional review board approval, a review of 22 FAPI prevalence studies from 2009 to 2016 was conducted based on 3310 patients in 2 hospitals. A root-cause analysis (RCA) was conducted for each FAPI. The FAPI rate ranged from 0.8% to 4.7% during the 7-year period. The average FAPI rate excluding stage 1 was 1.99%, which is lower than the national 2015 FAPI rate excluding stage 1 of 2.5%. The FAPI rate has decreased during the 7-year period. RCAs revealed common FAPI sites (coccyx, sacrum, and heels), consistent with current research. Limitations included a convenience sample. The FAPI rate has potential for error due to reliance on documentation in the medical record and if patients with FAPIs are counted more than once in sequential measurement. FAPI prevalence data are essential in analyzing rates and trends including 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. Research implications include continued quarterly data collection of FAPI prevalence in both hospitals and further data analysis examining relationships between Braden Scale risk scores, demographic variables, and FAPIs.

Agency for Healthcare Research and Quality. (Pressure ulcer treatment strategies: comparative effectiveness. Published 2013.

Agency for Healthcare Research and Quality. Toolkit for using the AHRQ quality indicators: how to improve hospital quality and safety. http:// Published 2016.

National Pressure Ulcer Advisory Panel. NPUAP announces change in terminology. http:// Published 2016.

NYS Gold STAMP Program Pressure Ulcer Resource Guide. http:// Published 2013.

Wound—Evidence-Based Interventions



Gale Roxanna Lupien, MSN, RN, CNL, CWOCN, CFCN, , and Radoslava Stoddard, BSN, RN, CWON, CFCN, , Nursing Administration, St Louis, MO

BACKGROUND: Pressure ulcer prevention has become an essential role of the CWOCN, especially since the Centers for Medicare & Medicaid Services began holding acute care hospitals accountable for hospital-acquired stage 3 and stage 4 pressure injuries. We are to utilize evidence-based practice and remain fiscally responsible. While utilizing a venous thrombosis embolism sleeve, pressure injuries were developing along the Achilles and heel area of our critically ill patients wearing a plastic frame podus boot, resulting in device-related pressure injuries. After trialing 2 heel suspension boots recently introduced to the market, we chose the newest product, a soft upholstered heel off-loading boot (soft boot). We needed to ensure we had an effective tool to reduce our incidence of heel pressure injuries. PURPOSE AND METHODS: The purpose of this study was to compare the effectiveness of 2 types of medical heel off-loading devices in preventing hospital-acquired pressure injuries (HAPIs) to the heel and the foot. A retrospective comparison study was designed to evaluate the 2 different heel off-loading devices and the incidence of heel/foot HAPI in the facility. An institutional review board approval was obtained (protocol no. 27149), and data were collected for 4-month periods over 3 years: 2014, 2015, and 2016. Medical records of 2872 patients were reviewed for heel/foot HAPI. Patients identified with heel/foot pressure injuries had additional information collected including Braden Scale score, gender, age, and stage of wound. Using statistical software, the 1- and 2-sided Fisher exact test was completed. Patient populations and acuity of illness were similar between the groups. RESULTS: The statistical analysis found the soft boot heel/foot HAPI rate was significantly lower, a 10-fold lower incidence rate than the podus-type boot. The effectiveness of newer products requires validation.

1. 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: Clinical Practice Guideline. Cambridge Media: Osborne Park, Western Australia; 2014.

2. US Department of Health and Human Services. Health, United States, 2015. Washington, DC: US Department of Health and Human Services; 2016:37–38. DHHS Publication No. 2016-1323.

3. Meyers TR. Preventing heel pressure ulcer and plantar flexion contractures in high-risk sedated patients. J Wound Ostomy Continence Nurs. 2010;37(4):372–378.

Ostomy—Psychosocial and Quality-of-Life Aspects



Midori Nagano, PhD, RN, CN(WOC), , Nursing Administration, Tokyo, Japan; Yasuko Ogata, PhD, RN, PHN, MM, , Department of Gerontological Nursing and Care System Development, Tokyo, Japan; Masaomi Ikeda, PhD, RDT, BSc, , Oral Prosthetic Engineering, Graduate School, Tokyo, Japan; and Kunio Tsukada, MD, PhD, , Takaoka Ekinan Clinic, Takaoka-si, Keiko Tokunaga, BSN, RN, ET, , Miyagi University, Kurokawa-gun Miyagi-ken, and Satoshi Iida, MD, PhD, , Colorectal Surgery, Fukushima, Japan

OBJECTIVE: The number of ostomates requiring support for independence in changing their ostomy appliances is growing as a result of the increasing incidence of colon cancer, aging society, and the shortening of hospitalizations. Ostomates are more inclined to have peristomal irritant dermatitis from their ileostomy due to the progress of treatment and expansion of chemotherapy. This study described characteristics of living with an ostomy based on the factors of independence in changing appliances and existence of peristomal irritant dermatitis. METHODS: This retrospective survey was conducted from patients' outpatient and inpatient treatment records of rectal cancer ostomy surgery and who had visited a stoma clinic between 2008 and 2014. RESULTS: Records from a total of 44 colostomates and 57 ileostomates were examined. Overall, 33.7% of ostomates required assistance with changing ostomy appliances at 8 weeks after surgery and 29.3% required assistance at 16 weeks after surgery. Significantly more ostomates older than 65 years required assistance than those younger than 65 years (P < .01) and also for diabetic patients (P < .01). In total, 36% of ostomates had peristomal irritant dermatitis. The incidence of peristomal irritant dermatitis was higher for those with ileostomies than for those with colostomies (odds ratio = 3.101) and was also higher among patients receiving chemotherapy (odds ratio = 2.483). CONCLUSION: Advance age and diabetes reduced patients' ability in changing ostomy appliances. Ileostomy and chemotherapy disposed patients to peristomal irritant dermatitis. Most rectal cancer patients with a stoma were at risk for both or either. Stoma clinics must strengthened consultation correspondence and resource functions for local medical welfare professionals. In particular, this support should include preoperative assessment and long-term care.

Pittman J, Rawl SM, Schmidt CM, et al Demographic and clinical factors related to ostomy complications and quality of life in veterans with an ostomy. J Wound Ostomy Continence Nurs. 2008;35(5):493–503.

Pittman J, Kozell K, Gray M. Shoud WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36(3):254–265.

Sung YH, Kwon I, Jo S, Park S. Factor affecting ostomy-related complications in Korea. J Wound Ostomy Continence Nurs. 2010;37(2):166–172.

Burgdorf SK, Rosenberg J. Short hospital stay after laparoscopic colorectal surgery without fast track. Minim Invasive Surg. 2012;12:260273.

Wound—Product Selection and Innovations



Dan Li, PhD, RN, , Department of Health and Community Systems, Pittsburgh, PA; and Carol Mathews, BSN, RN, CWOCN, , University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, PA

Objective and accurate assessment of pressure injury/ulcer (PI/U) healing is needed to deliver better wound care to patients. Progress in wound healing is primarily quantified by the rate of change of PI/U dimensions. However, accurate measurement of PI/U dimension is challenging due to the complexities of PI/U itself and clinical environment. Photographing PIs/Us has become a standard practice in nursing documentation at many hospitals today. With special software and tool's help, PI/U dimensions can be estimated from PI/U images. Performed manually, this process is very time-consuming and subject to intra- and inter-reader variability. Here, we present our methodology to segment and measure the enclosed PI/U area from photographic PI/U images at clinical settings automatically. The first step of our method is to transform the images with RGB (Red, Green, and Blue) color space to YCbCr color space, which help us eliminate the inferences from light and skin colors. A probability map, generated by the skin color Gaussian model, guides the PI/U segmentation process using a Support Vector Machine classifier. After PI/U is segmented from the images, the reference ruler helps complete perspective transformation and determine the size of PI/U. A total of 32 PI/U images measured by WOC nurses were used to validate the PI/U measurement from the image processing technologies. The results showed that intrarater reliability of the measurements of length, width, and surface area was all 0.89. The interrater reliability of length, width, and surface area was 0.89, 0.87, and 0.88, respectively. The innovative aspects of this work include defining a probability map specific to healthy skin and PI/U characteristics, a computationally efficient method to segment PI/U images utilizing the probability map, and computerized PI/U measurements with consideration of perspective transformation. In addition, a high accuracy on PI/U measurement was achieved by our method through comparisons with WOC nurses' measurement.

Wound—Evidence-Based Interventions



Radoslava Stoddard, BSN, RN, CWON, CFCN, , and Gale Roxanna Lupien, MSN, RN, CNL, CWOCN, CFCN, , Nursing Administration, St Louis, MO

Pressure injuries (PIs) are associated with increased discomfort, length of stay, cost, and mortality; annual US cost for PI care is estimated to approach $11 billion. Our previous protocol for PI prevention included low air loss mattresses, sacral foam dressings for Braden Scale score of less than 18, and continuous lateral rotation therapy (CLRT) at 80% to 100% to achieve a 30° turn. Our level 1 trauma center has 5 intensive care units (ICUs) for complex patient needs. Hemodynamically unstable patients had difficulty tolerating aggressive CLRT and were developing sacral PIs. To address this problem, we continued with our previous PI protocol and created a treatment algorithm for the additional use of a Patient Positioning System (PPS). The PPS was used instead of CLRT for patients at the highest risk for PI based on evidence-based clinical criteria. We collected and analyzed our hospital-acquired PI (HAPI) data to evaluate if the use of the PPS impacted our HAPI rates. We retrospectively compared two 9-month periods of HAPI in our ICU patients. Group 1: Pre-PPS intervention has 18 ICU PIs (January 2014-September 2014). Group 2: Post-PPS intervention has 8 ICU PIs (December 2015-August 2016). Hemodynamically unstable patients were able to tolerate the PPS. Both groups were similar with acuity, age, and Braden Scale score. The addition of the PPS allowed our highest-risk patients to receive effective turning and resulted in a decrease in our PI rate by over 50%. Implementation of the PPS resulted in a nursing culture change facilitating decreasing HAPIs and improving nursing satisfaction.

1. Cox J. Predictors of pressure ulcers in adult critical care patients. Am J Crit Care. 2011;20(5):364–375.

2. 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: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

Wound—Product Selection and Innovations



Cathleen T. Van Houten, MS, RN, CNS, CWON, , Adult Critical Care & Pediatric Nursing, Rochester, NY; Dana Chimino, BSN, RN, CNOR, RNFA, , and Robert Hance, MS, RN, CNOR, , Perioperative Nursing, Rochester, NY; and Luba Fingerut, BSN, RN, CCRN, , Cardiovascular Nursing, Rochester, NY

BACKGROUND: Patients in the cardiovascular intensive care unit (CVICU) represent some of the most critically ill patients in the hospital. The literature supports that hypotension, anesthesia, length of surgery, increased humidity and temperature, and altered tissue perfusion and oxygenation are among risk factors that contribute to pressure injury development. At a Magnet-designated tertiary care hospital, more cardiac surgery patients developed occipital pressure injuries than any other service line. PURPOSE: To evaluate and implement a strategy to off-load occiput pressure to reduce the number of occipital pressure injuries associated with cardiac surgery. METHODS: A group of physicians and nurses met to discuss the high incidence of occipital pressure injuries. A subgroup including perioperative nurses, CVICU nurses, and a certified wound specialist nurse tested multiple options for off-loading the occiput using a pressure-mapping device. Consensus regarding trial product selection was based on the following: pressure-mapping results, price, preference for a single-patient use item versus a product that would need disinfection/sterilization, and agreement from all stakeholders including anesthesiology. During the 6-month observational trial period, a single-patient use contoured memory-foam pillow was placed under every patient's head (n = 461) prior to the start of cardiac surgery and subsequently used throughout the ICU stage of hospitalization. The number of occipital pressure injuries prior to the intervention was compared to the number that occurred during the trial period. RESULTS: During the pretrial period, 9 occipital pressure injuries occurred; during the trial period, 1 occipital pressure injury developed; and no additional ones have occurred since the end of the trial and continued use of the pillow. CONCLUSIONS: No other new prevention initiatives were implemented during the trial period; thus, it is fair to conclude that the pillow-based intervention eliminated hospital-acquired occipital pressure injuries among CVICU patients.

Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Manage. 2007;53(2):57–69.

Haesler E, ed. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia: Cambridge Media; 2014.

Sewchuk D, Padula C, Osborne E. Prevention and early detection of pressure ulcers in patients undergoing cardiac surgery. AORN J. 2006;84(1):75–96.

Steinmetz JA, Langemo DK. Changes in occipital capillary perfusion pressures during coronary artery bypass graft surgery. Adv Skin Wound Care. 1996;9(3):28–32.

Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN J. 2009;89(3):538–552.

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



Tara Konicki, PhD, RN, , and Misty Richmond, PhD, PMHNP-BC, , College of Nursing and Health, Dayton, OH

Pressure ulcers in the intensive care unit setting add to the cost of care in this critically ill population. Prevalence and incidence in individual studies have been found to vary widely. The objective of this analysis was to determine the prevalence and incidence of pressure ulcers in the intensive care unit patient population. Nonexperimental research studies were included in the meta-analyses. Data were extracted by 2 researchers, and differences were resolved by consensus. The random-effects model was used for all analyses. Meta-analysis of 26 studies resulted in an incidence of 13.5% (95% confidence interval [CI], 0.10-0.179). Meta-analysis of 8 incidence studies begun in 2007 and later had an incidence rate of 16.5% (95% CI, 0.90-0.28). The prevalence rate after analysis of 3 studies was 20.3% (95% CI, 0.09-0.40). Significant heterogeneity was present in all studies. The presence of heterogeneity was expected due to the various types of intensive care unit settings, the varying levels of patient acuity, and the different sets of inclusion criteria across studies.

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. doi:10.1111/j.1365-2702.2008.02554.x.

Preventing Pressure Ulcers in Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; 2014. http://

Shahin ESM, Dassen T, Halfens RJG. Pressure ulcer prevalence in intensive care patients: a cross-sectional study. J Eval Clin Pract. 2008;14(4):563–568.

Vangilder 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):39–45.

Ostomy—Product Selection and Innovations



Lea Crestodina, ARNP, CWOCN, CDE, , Wound Care, Coral Springs, FL

PURPOSE: The purpose of this historical poster was to examine the evolution of ostomy surgery, the ostomy nurse specialist, and the corresponding evolution of ostomy products. METHODOLOGY: This poster was created by reviewing historical records in nursing journals and medical textbooks and through interviews with patients who have undergone ostomy surgery in the 1950s, 1960s, and 1970s. STATISTICS: Statistics were not utilized, as this was a historical research project. RESULTS: Ostomy surgery continues to evoke great emotion. Since the onset of this lifesaving surgery, patients undergoing ostomy surgery have had many emotions ranging from relief at having another chance at life to dread, fear, and shame. This historical research poster outlines the history of ostomy surgeries through the years and the corresponding evolution of pouching systems. These systems have allowed patients to move forward with their lives and without the pouching systems; the surgeries surely would not have been successful. This study also parallels the evolution of the ostomy nurse specialist. The ostomy nurse specialist is familiar with all of the surgical procedures and the different pouching systems available to help equip patients with a system to keep them dry and confident. It was not always this way. Early on, there were no ostomy nurse specialists and patients needed to rely on other ostomy patients and their practical knowledge to help them move forward. These were the beginning of the role of the ostomy nurse specialist. CONCLUSION: This poster is a presentation of the historical role of the surgeon, the commercial pouch companies, and the ostomy nurse specialist in the evolution of the colostomy, ileostomy, and ileal conduit.

Wound—Management of Complex Wounds



Rajeshwar Nath Srivastava, , and Mukesh Kumar Dwivedi, , Department of Orthopaedic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India; Amit Kumar Bhagat, , Department of Surgical Gastroenterology King George's Medical University, Lucknow, UP, India; and Saloni Raj, , Bengaluru, Karnataka, India

INTRODUCTION: Pressure injury (PI) is devastating comorbidity in spinal cord injury (SCI) subjects and difficult to treat. Some studies show mixed results using bone marrow stem cells to treat several diseases including chronic wounds. The aim of this pilot study was to assess the safety and efficacy of bone marrow–derived stem cell therapy to promote the healing of PI in patients with SCI. MATERIAL AND METHODS: Ten patients having stage IV PI were enrolled and equally divided into 2 groups: group 1 patients (5) were given bone marrow-mononuclear cells (BM-MNCs), followed by dry gauze daily dressing; and group 2 patients (5) were given only dry gauze dressing as standard wound care. Among group 1 patients, 100 mL of bone marrow (BM) was harvested from the posterior iliac crest. BM-MNC suspension was separated from BM immediately after harvesting. BM-MNCs were injected by insulin syringe after the wound was subdivided with a grid into small areas of 1 cm2. Wound assessment for healing outcome measures in both the groups was done at weeks 0, 3, 6, and 9. Wound biopsy was done at every 3 week to assess the metastasis. Results: PI treated with BM-MNCs had fully healed after 6 week. When compared to group 2 patients, a significant reduced surface area was observed in BM-MNC-treated PIs at week 6 (P = .001). Conversion of slough into red granulation tissue was significantly higher in the BM-MNC group after week 6 (P = .001). None of the biopsies showed signs of metaplastic proliferation/differentiation after BM-MNC therapy. CONCLUSIONS: This pilot study indicate that autologous BM-MNC therapy is safe and could be an option to treat type IV pressure ulcers in patients with SCI. A larger study may help test the efficacy of this therapy to treat PI.

González Sarasúa J, Pérez López S, Álvarez Viejo M, et al Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury. J Spinal Cord Med. 2011;34(3):301–307.

Menendez-Menendez Y, Alvarez-Viejo M, Ferrero-Gutierrez Am, et al Adult stem cell therapy in chronic wound healing. J Stem Cell Res Ther. 2014;4:1.

Wettstein R, Savic M, Pierer G, et al Progenitor cell therapy for sacral pressure sore: a pilot study with a novel human chronic wound model. Stem Cell Res Ther. 2014;5:18.



Sandra Marina Gonçalves Bezerra, , Professor of Nursing, Teresina, Italy; Maria Clara Batista da Rocha Viana, , Teresina, Italy; Aline Costa de Oliveira, , Nursing, Teresina, Italy; Daniel de Macedo Rocha, , Nursing coordination, Teresina, Italy; Lidya Tolstenko Nogueira, , Nursing coordination, Teresina, Italy; and Raquel Rodrigues dos Santos, , Enfermagem, Teresina, Italy

PURPOSE: To assess the cost of treatment in patients with complex wounds. DESIGN: An evaluative, descriptive study conducted in a public clinic in the city of Teresina specialized in complex wounds. SUBJECTS AND SETTING: The sample consisted of 107 patients presenting with acute and chronic wounds to perform a dressing from January to April 2015. METHODS: Data collection was guided by a semistructured instrument, containing information about the sociodemographic profile, associated comorbidities, number of wounds, used covers, and cost of topical treatment. For data analysis, the SAS 9.0 software program was used. RESULTS: There was a predominance of men (64.49%) and young adults (69.16%), with a prevalence of acute injuries related to motorcycle accidents (53.6%). The main cover used was calcium alginate (48.6%), followed polyurethane foam with silver (15.89%). The initial wound area ranged from 2 to 1530 cm2, and the average healing time was 2 months (31.78%). The cost of treatment ranged from US $9.3 to US $428.6 per wound. The research demonstrated through significant correlation the Spearman correlation test (P < .05) between the total cost of treating wounds and used covers. It was verified that wounds smaller than 50 cm2 have a compatible cost with the tabulated value by the Brazilian Health Unic System (SUS) and using extensive silver toppings become more expensive and the amount paid is less than the cost of treatment. CONCLUSION: It is concluded that the direct cost of materials and roofing is only compatible with the disbursement of SUS for small wounds. It is necessary to evaluate indirect costs and is cost-effective for longer than 6 months, given the complexity and extent of traumatic wounds that need to be treated by the multidisciplinary team and the surgical procedure as autologous skin grafting.

KEY WORDS: complex wounds, cost analysis, nursing.

Silva AJ, Pereira SM, Rodrigues A, et al Economic cost of treating pressure ulcers: a theoretical approach. Rev Esc Enferm. 2013;47(4):971–976. http:// Accessed November 2, 2016.

Evangelista DG, Magalhães ERM, Moretão DIC, Stival MM, Lima LR. Impact of chronic wounds in the quality of life for users of family health strategy. Rev Enferm Cent Min. 2012;2(2):254–263. http://

Continence—Assessment Techniques



Mukesh Kumar Dwivedi, , and Rajeshwar Nath Srivastava, , Department of Orthopaedic Surgery, King George's Medical University, Lucknow Uttar Pradesh, India; Amit Kumar Bhagat, , Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India; and Saloni Raj, , Bengaluru, Karnataka, India

INTRODUCTION: We studied the relationship of pressure injury (PI) matrix metalloproteinase-8 with healing rate in spinal cord injury (SCI) patients. Our aim was to assess the surface area and depth of PI, exudate amount, tissue type, and level of MMP-8 in PI treated with negative pressure wound therapy (NPWT) and PI treated with dry gauze dressing as standard wound care. MATERIAL AND METHODS: A cohort of 44 SCI patients having stage III/IV sacral PI were randomized into 2 groups: one (n = 21) received NPWT with a locally constructed negative pressure device, and other (n = 23) received dry gauze dressing as a standard wound care. The PI was treated until the wound closure or up to 9 weeks. Levels of MMP-8 were analyzed at weeks 0, 3, 6, and 9 by ELISA. RESULTS: Significant lower level of MMP-8 was observed in the NPWT group at week 6 and week 9 as compared to the standard care group. Significant reduced surface area was observed in PI of the NPWT group at week 6 (P = .04) and week 9 (P = .001). Significant reduction of depth of PI was also observed in the NPWT group at week 9 (P < .05). Pearson's correlation analysis showed significant positive correlation of MMP-8 with surface area and depth at weeks 0, 3, 6, and 9 in the NPWT group. In contrast to the NPWT group, significant negative correlation of MMP-8 was observed with surface area and depth at weeks 0, 3, 6, and 9. Exudate levels became significantly (P = .001) lower in the NPWT group compared to standard care from week 3. Conversion of slough into granulation tissue was significantly higher in the NPWT group after week 6 (P = .001). CONCLUSIONS: Levels of MMP-8 can be used to indicate the prognosis of PI and NPWT used to improve healing rates as a protease-modulating treatment.

McCarty SM, Percival SL. Proteases and delayed wound healing. Adv Wound Care. 2013;2(8):438–447. doi:10.1089/wound.0370.

Schultz GS, Wysocki A. Interactions between extracellular matrix and growth factors in wound healing. Wound Repair Regen. 2009;17:153–162.

Danielsen PL, Holst AV, Maltese HR, et al Matrix metalloproteinase-8 over expression prevents proper tissue repair. Surgery. 2011;150:897–906.

Kilpadi DV, Mtechmiller JK, Childress B, et al Composition of wound fluid from pressure ulcers treated with negative pressure wound therapy using V.A.C. therapy in home health or extended care patients: a pilot study. Wounds. 2006;18:119–126.

Wound—Product Selection and Innovations



Adrienne Gilligan, PhD, , Rich Bizier, BS, , and Bong Chul Chu, PhD, , Ann Arbor, MI; Curtis Waycaster, PhD, , Market Access, Fort Worth, TX; Marissa Carter, PhD, MA, , Strategic Solutions, Inc, Cody, WY; and Caroline Fife, MD, CWS, , Geriatrics, Houston, TX

OBJECTIVE: Assess the 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 pressure ulcers (PUs). METHODS: Retrospective de-identified electronic medical records from 2007 to 2013 were extracted from the US Wound Registry (USWR). Propensity score-matching method was used to adjust for selection bias and to test for treatment effect between PUs treated with CCO versus MH. Outcomes of interest included 100% granulation of the wounds at 1 year, epithelialization of the wounds at 1 and 2 years, and measures of resource utilization. RESULTS: A total of 517 CCO PUs were matched to corresponding 517 MH PUs (mean age: 66.2 years vs 63.6 years). The majority of PUs in the CCO and MH cohorts were stage III (56% vs 55%) and located on the sacrum/buttock (32% vs 37%). Compared to MH, CCO patients had significantly fewer HOPD visits (9.1 vs 12.6), fewer selective sharp debridements (2.7 vs 4.4), and less likely to receive negative pressure wound therapy (29% vs 38%) (all Ps < .01). PUs treated with CCO were 38% more likely to achieve 100% granulation compared to MH PUs at 1 year (P = .018). The average number of days to 100% granulation was significantly lower for PUs treated with CCO (255 days vs 282 days, P < .001). CCO-treated PUs were 47% and 39% more likely to epithelialize at 1 and 2 years compared to MH-treated PUs (P < .01 for both values). The average number of days to epithelialization was significantly lower for CCO-treated PUs at 1 and 2 years (288 days vs 308 days and 549 days vs 595 days, P < .01 for both values). CONCLUSION: PUs treated with CCO demonstrated significant clinically meaningful advantages over MH in all stages of PUs in regard to granulation tissue formation and subsequent epithelialization.

Wound—Preventative Practices New



Susan Kayser, PhD, , Innovation, Batesville, IN; Catherine VanGilder, MBA, BS, MT, CCRA, , Clinical Research, Chicago, IL; and Charlie Lachenbruch, PhD, , R&D, Batesville, IN

PURPOSE: Limited evidence exists regarding how patient characteristics may increase the risk of developing severe hospital-acquired pressure injuries (HAPIs), defined as stage III plus. This analysis aimed to understand and compare the relationships between patient demographics and clinical characteristics with the presence of any pressure injury (PI), HAPIs, and severe HAPIs. METHODS: Data from the IPUP's observational, cross-sectional cohort database were analyzed after institutional review board (IRB) exempt determination (Schulmann IRB #201606306). Observations were limited to 2011-2016 US acute care subjects who had complete data within acceptable limits. Three logistic regressions examined associations between patient demographics and clinical characteristics with having any PI, HAPIs, or severe HAPIs. RESULTS: IPUP data 2011-2016 (n = 636,695) were filtered for complete valid data (n = 252,784); 26,150 subjects had a PI, 9498 had an HAPI, and 3242 had a severe HAPI. The following factors were associated with all 3 PI categories (P < .001): age, male gender, longer length of stay (LOS), increased linen layers, and lower Braden Scale scores. Risk of all PI categories increased at both ends of the weight spectrum. All types of incontinence (urinary, fecal, fecal management system, catheter, or an ostomy) were positively associated with the presence of any type of PI and HAPIs (odds ratio [OR] range, 1.24-2.95; P < .001). Incontinence—excluding urinary—was also a significant predictor of severe HAPIs. Intensive care unit patients were less likely to have any PI (OR = 0.90; P < .001) but more likely to develop HAPIs (OR = 1.37; P < .001) or severe HAPIs (OR = 1.85; P < .001), controlling for the aforementioned factors. CONCLUSION: Severe HAPIs lead to longer LOS, greater hospital costs, and higher mortality. We found evidence that hospitals reported fewer HAPIs over time; however, that did not hold for severe HAPIs. Furthermore, we found that patients with fecal incontinence were at greater relative risk of developing severe HAPIs (OR = 2.22) than any stage HAPIs (OR = 1.90), highlighting the importance of managing incontinence.

Coleman S, Gorecki C, Nelson EA, et al Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50(7):974–1003.

Lachenbruch C, Ribble D, Emmons K, VanGilder C. Pressure ulcer risk in the incontinent patient: analysis of incontinence and hospital-acquired pressure ulcers from the International Pressure Ulcer Prevalence™ Survey. J Wound Ostomy Continence Nurs. 2016;43(3):235–241.

Ostomy—Psychosocial and Quality-of-Life Aspects



Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL; and Gary Inglese, MBA, RN, , Libertyville, IL

INTRODUCTION: Peristomal skin complications (PSCs) have a profound impact on health-related quality of life (QOL) for those individuals with stomas. PSCs are health stressors influencing the burden of health of the ostomate. It is estimated that PSCs affect upwards of two-thirds of ostomates at some point in time.1 A difficulty encountered by researchers assessing PSCs is the inability to separate this burden from the general health of the ostomate. OBJECTIVE: It was the aim of this study to quantify the relationship between PSCs, health utility, and QOL in an ostomy sample (n = 2329). METHODS: Utilizing the SF36v2,2 the SF6D,3 and a visual analog scale assessing QOL (scale = 0-100), we present the burden of health as represented by health utility and QOL associated with 3 levels of PSCs controlling for general health. The study is a cross-sectional survey. Analysis includes descriptive statistics and analysis of covariance. Covariates are age and time from surgery. Institutional review board approval was obtained for the conduct of the study. RESULTS: The data provide empirical evidence that as general health of the ostomate increases, there is a corresponding health utility and QOL increase that can be influenced by PSCs. As PSC severity changes, there are corresponding directional changes in health utility and QOL. The average adjusted health utility for those reporting no PSCs is found to be 0.76 (QOL = 81.2). The average adjusted health utility for those reporting mild to moderate PSCs is 0.70 (QOL = 76.7), while for those reporting severe PSCs this is 0.63 (QOL = 65.6). CONCLUSIONS: PSCs affect more than the obvious skin health of those with a stoma. The role of the stoma care nurse in intervening and managing skin health is an integral part of enhancing the health-related quality for those living with a stoma.

1. Lyon CC, Smith AJ. Abdominal Stomas and Their Skin Disorders: An Atlas of Diagnosis and Management. London, England: Martin Dunitz Ltd; IX.

2. SF36v2. Lincoln, RI: QualityMetric Incorporated.




Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL

INTRODUCTION: Peristomal skin problems affect the well-being of those who must cope and adapt to their impact. Compromised peristomal skin health can intermittently affect day-to-day living in those who have undergone ostomy surgery. Peristomal skin dermatoses are reported to be a significant problem affecting upwards of two-thirds of ostomates.1 Peristomal skin complications are health stressors, and it may be expected that their effect is cumulative to include social impact and the cost to society. Of interest is the impact that peristomal skin health has on social interactivity of the person who has undergone ostomy surgery. OBJECTIVE: It was the objective of this analysis to assess the relationship between peristomal skin complications, social interaction, and health utility in an adult US population. METHODS: This is a cross-sectional survey (n = 2329) utilizing the SF36v2 survey instrument,2 the SF6D,3 indices of social interactivity, and self-reported measures of peristomal skin condition. Institutional review board approval was obtained for the conduct of the study. Statistical analysis includes generalized linear models utilizing analysis of covariance. Covariates in this study are time from surgery and age of the respondent. RESULTS: The study provides empirical evidence that as social interactivity increases, there is a corresponding increase in health utility. This is shown to be significantly impacted by peristomal skin condition, that is, as peristomal skin condition increases or decreases in severity, there are significant corresponding directional changes in health utility. The health utility changes associated with changes in peristomal skin health, and resulting changes in social interactivity, are representative of a minimally important social value of peristomal skin health. CONCLUSIONS: The successful clinician does far more than treat a patient. The clinician adds value to the community. Peristomal skin health is a capital asset that allows an investment in community that can be realized as an overall socioeconomic benefit to the society.

1. Lyon CC, Smith AJ. Abdominal Stomas and Their Skin Disorders: An Atlas of Diagnosis and Management. London, England: Martin Dunitz Ltd; IX.

2. SF36v2. Lincoln, RI: QualityMetric Incorporated.


Ostomy—Stomal/Peristomal Complications



Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL; and Cale Street, PhD, , Global Marketing, Libertyville, IL

INTRODUCTION: A global evaluation of ceramide-infused ostomy skin barriers was conducted. The evaluation involved 184 stoma care nurses from 4 countries enrolling 284 patients. The countries involved were Australia, Germany, the United Kingdom, and the United States. Of the 284 patients evaluated, 33% were colostomates (mean age = 63.1 years), 51% were ileostomates (mean age = 54.7 years), and 16% were urostomates (mean age = 66.6 years). OBJECTIVE: It was the objective of this product evaluation to assess peristomal skin health in the presence of a ceramide-infused skin barrier. RESULTS: Of interest was the condition of peristomal skin prior to the use of ceramide-infused skin barriers and after. Peristomal skin condition was assessed using the Skin Assessment Tool1 (for Discoloration, Erosion, and Tissue Overgrowth [DET]; scale = 0-15) and categorized according to Meisner2 as mild skin (<4), moderate (≥4 and <7), and severe (≥7). The data indicate that of 66 ostomy patients assessed as having a severe peristomal skin condition prior to the use of ceramide-infused skin barriers, 52% were assessed as having mild peristomal skin and 24% were assessed as having moderate peristomal skin condition after the use of ceramide-infused skin barriers (24% remained unchanged). The data also indicate that of 78 patients assessed with a moderate peristomal skin condition prior to the use of ceramide-infused skin barriers, 74% were assessed as having mild peristomal skin condition after the use of ceramide-infused skin barriers (22% remained the same). For those patients in whom skin conditions improved, an approximate 1 day longer product wear time was observed, while the use of topical medications and accessories was indicated as having been reduced in 37% and 48% of patients, respectively. CONCLUSIONS: In this product evaluation, improvements in peristomal skin condition were associated with the use of a ceramide-infused skin barrier.

1. Jemec GB, Martins L, Claessens I, et al Assessing peristomal skin changes in ostomy patients: validation of the ostomy skin tool. Br J Dermatol. 2011;164(2):330–335.


Ostomy—Product Selection and Innovations



Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL

INTRODUCTION: Recent evidence indicates that ceramide-infused skin barriers may offer benefits to peristomal skin while retaining the advantages of traditional hydrocolloid barriers.1 A global evaluation of ceramide-infused ostomy skin barriers was conducted involving 184 stoma care nurses enrolling 284 patients from Australia, Germany, the United Kingdom, and the United States. Of the 284 patients evaluated, 33% were colostomates (mean age = 63.1 years), 51% were ileostomates (mean age = 54.7 years), and 16% were urostomates (mean age = 66.6 years). Eighty-four percent of patients were indicated as having been diagnosed with various skin conditions including acute and chronic irritant dermatitis, product sensitivities, maceration, and fungal rashes. Stoma care nurses were provided with ceramide-infused skin barriers and asked to use the barriers according to their standard of care. OBJECTIVE: To determine clinician satisfaction with a ceramide-infused skin barrier. RESULTS: The nurses expressed satisfaction with the ceramide-infused skin barriers for use in the patients they evaluated. In 88% of patients evaluated, the nurses were satisfied or very satisfied with overall performance of the ceramide-infused skin barriers. In 95% of the patients evaluated, the nurses were satisfied or very satisfied with ease of use and application of the skin barriers; for the issue of barrier adherence, this was 92%; for the issue of ease of removal, this was 90% and wear time was 87%. The nurses were asked how likely they would be to continue to use or recommend the ceramide-infused skin barrier for the patients evaluated. Of 269 responses to this question, 84% indicated “likely” or “very likely.” CONCLUSIONS: The analysis of the data indicates an overall favorable response to the use of the ceramide-infused skin barriers to the extent that nurses, in general, would continue to use or recommend the ceramide-infused skin barriers for their patients.

1. Hoeflok J. Experiences with a ceramide infused hydrocolloid skin barrier. WCET J. 2016;36(3):16–20.



Thomas Nichols, MS, MBA, , Health Economics, Libertyville, IL; and Gary Inglese, MBA, RN, , Libertyville, IL

INTRODUCTION: A global evaluation of a novel ceramide-infused skin barrier was conducted in 2015 and 2016. The evaluation involved 184 nurses from 4 countries enrolling 284 patients (2015-2016). Of primary concern in the evaluation was the condition of peristomal skin prior to the use of ceramide-infused skin barriers and after the use of the ceramide-infused skin barriers. Peristomal skin condition was assessed using the Skin Assessment Tool scored for Discoloration, Erosion, and Tissue Overgrowth (DET; scale = 0-15).1 OBJECTIVE: To analyze peristomal skin condition of patients in a product evaluation in which there was an existing diagnosis of acute or chronic irritant dermatitis. RESULTS: Thirty-nine patients had valid DET scores and an existing diagnosis of acute irritant dermatitis, with no other skin conditions noted. Prior to the use of the ceramide-infused skin barriers, a cumulative assessment of these patients indicated a mean DET score of 5.10 (moderate peristomal skin complications). After the use of the ceramide-infused barriers, the assessment indicated a mean DET score of 1.54 (mild peristomal skin complications). Twenty-four patients had valid DET scores and an existing diagnosis of chronic irritant dermatitis, with no other skin conditions noted. Prior to the use of the ceramide-infused skin barriers, a cumulative assessment of patients indicated a mean DET score of 7.00 (moderate peristomal skin condition). After the use of the ceramide-infused barriers, the assessment indicated a mean DET score of 3.33 (mild peristomal skin complications). Of those with acute or chronic irritant dermatitis, 1 (1.6%) had worsening in skin condition, 11 (17.5%) stayed the same, and 51 (80.9%) had improvements in peristomal skin condition. CONCLUSIONS: In this product evaluation, ceramide-infused skin barriers were associated with improvements in peristomal skin condition.

1. Jemec GB, Martins L, Claessens I, et al Assessing peristomal skin changes in ostomy patients: validation of the ostomy skin tool. Br J Dermatol. 2011;164(2):330–335.

Wound—Preventative Practices New



David Brienza, PhD, , Patricia Karg, MSE, , and Michael Churilla, BS, , Pittsburgh, PA; and Vinoth Ranganathan, MSE, MBA, , Chicago, IL

Lengthy surgeries often expose bony prominences to loading conditions associated with high risk of pressure injuries. Of 1.6 million pressure injuries that develop in acute care settings annually, roughly 25% are acquired intraoperatively during surgeries that last more than 3 hours.1 Prolonged ischemia may be one of the factors increasing risk.2 Alternating pressure (AP) has been shown to increase skin blood flow (SBF).3 This study compared the response of sacral skin blood flow on a foam operating room (OR) pad with and without an AP overlay. An experimental, crossover research design was conducted in the laboratory with and without an AP overlay on a foam OR pad. Healthy participants (n = 10) with mean age of 27.5 ± 5.7 years and body mass index (BMI) of 26.8 ± 7.0 kg/m2 laid supine for 60 minutes in each condition while sacral SBF data were collected using a laser Doppler optic probe. Mean SBF measurements were tested for significant differences between conditions. The loaded SBF data were normalized to the mean baseline SBF. The ratio of the mean normalized SBF of the last 10 minutes to the mean SBF of the first 10 minutes represented the SBF response to each test condition. The difference in this measure between test conditions quantified the relative effectiveness. Post hoc analyses examined the relationships between the relative effectiveness and BMI and age. Mean SBF was not significantly different between test conditions (P = .53). Participant BMI had a strong negative correlation to difference in SBF response between conditions (r =−0.89, P < .001). Relative blood flow increase with the AP overlay was higher for participants with lower BMI. The relationship between SBF response and age was weak (r = 0.11, P = .74). The AP overlay was more effective at increasing sacral SBF over time than the OR pad alone in participants with normal BMI (<25 kg/m2).

1. Beckrich K, Aronovitch S. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nurs Econ. 1999;17(5):263–271.

2. Oomens CW, Bader DL, Loerakker S, Baaijens F. Pressure induced deep tissue injury explained. Ann Biomed Eng. 2015;43(2):297–305.

3. Jan Y, Brienza DM, Geyer MJ, Karg P. Wavelet-based spectrum analysis of sacral skin blood flow response to alternating pressure. Arch Phys Med Rehabil. 2008;89(1):137–145.



LeeAnn Phipps, PhD, , and Catherine VanGilder, MBA, BS, MT, CCRA, , Clinical Research, Chicago, IL; Susan Kayser, PhD, , Innovation, Batesville, IN; and Charlie Lachenbruch, PhD, , R&D, Batesville, IN

PURPOSE: Incontinence-associated dermatitis (IAD) is a type of irritant contact dermatitis in patients with fecal incontinence (FI) and/or urinary incontinence (UI). Limited evidence exists for IAD risk factors and how IAD relates to pressure injuries (PIs). The International Pressure Ulcer Prevalence Survey (IPUP) provides a large database from a variety of care settings and patient populations. This work explores patient and clinical characteristics associated with IAD and the relationship between IAD and PIs. METHODS: The 2016 annual IPUP survey included a new IAD question, asking whether a patient had IAD or not. A logistic regression was used to examine risk factors of IAD. Chi-squared tests were used to explore the relationship between IAD and PIs. Study-exempt status was determined by Schulman institutional review board (201605347). RESULTS: The 2016 IPUP survey data (n = 117,988) were filtered for subjects with complete valid range data in North America (n = 49,917) and limited to patients with UI, FI, or a Fecal Management System (n = 12,286). IAD prevalence was 17.4%. Regression analysis demonstrated significant relationships between IAD and the following factors: age, unit type, weight, longer length of stay (LOS), more linen layers, low Braden Scale score, and bed-restricted mobility (P < .05). Patients with FI or FI and UI were more likely to have IAD than patients with UI alone (P < .01). Chi-squared tests indicate that patients with IAD were more likely to have a PI (P < .001). DISCUSSION: This work represents the largest evaluation of IAD factors using a robust statistical model. IAD and PIs are challenging to differentiate but require distinct treatment strategies. Risk factors that are known to be associated with PIs were also found to be risk factors for IAD. Moreover, our data demonstrate that patients with IAD are more likely to suffer from PIs. This work highlights the importance of exploring causal relationships between IAD and PIs.



Donna Z. Bliss, PhD, RN, FAAN, FGSA, , Olga V. Gurvich, MA, , Susan Harms, PhD, RPh, , and Christine Mueller, PhD, RN, FAAN, FGSA, , School of Nursing, Minneapolis, MN; Lynn E. Eberly, PhD, , Biostatistics Division, School of Public Health, Minneapolis, MN; and Beth Virnig, PhD, , School of Public Health, Minneapolis, MN

BACKGROUND: Pressure injury prevalence is higher in black nursing home (NH) residents than whites, so prevention is critical. Incontinence is a risk factor for perineal pressure injury (PPrI). PURPOSE: To assess disparities in preventing PPrI in black NH residents who developed incontinence after NH admission. METHODS: Predictors of PPrI were from Minimum Data Set (MDS) records (residents' characteristics), more than 2 million practitioner orders (POs) for treatments/cares of residents, Online Survey, Certification, and Reporting (NH characteristics/staffing/care deficiencies) from 2000-2002, and 2000 US Census (socioeconomic status of communities around NHs). The cohort had 10,424 residents aged 65+ years (in 448 NHs in 27 states) who developed incontinence after admission, were free of PPrI, and were not receiving PrI prevention. In a cohort design, MDS and POs were searched for PPrI prevention from the day of incontinence until PPrI developed or records ended. Disparity was assessed with the Peters-Belson method: potential predictors of PPrI prevention were modeled for whites using logistic regression. Resulting coefficients were applied to minority groups in separate models estimating the percentage of minorities expected to receive PPrI prevention had they been in the white group. These percentages were then compared to the percentages observed to receive PPrI prevention using z-tests. RESULTS: The cohort was 71% female, aged 83 (7.6) years (mean [SD]), 89% white, and 8% black. There was a significant disparity in preventing PPrI in blacks (P < .001). The percentage of blacks observed to receive PPrI prevention (5.4%) was significantly less than expected had they been part of the white group (3%). Significant predictors (odds ratio [95% confidence interval]) of receiving PPrI prevention were older age (0.98 [0.96-0.99]), fewer cognitive deficits (0.87 [0.82-0.92]), % NHs in an urban area (1.44 [1.05-2.03]), and % residents receiving Medicaid (0.99 [0.98-0.99]). CONCLUSIONS: Eliminating disparities in preventing PPrI can improve health of incontinent black NH residents. WOC nurses can promote equity in care.

Ostomy—Product Selection and Innovations



Angie Perrin, MSc, BSc (Hons), DipN (Lond), RGN, ENB 216, , Research & Development, Birmingham, United Kingdom

Convex products have been commercially available for decades. In the early 1990s the very first integral convex appliance was developed, this product revolutionized stomal management. Since then there has been a myriad of integral convex appliances launched into the marketplace of varying depths and degrees of flexibility. Many specialist and nonspecialist nurses are being challenged to make critical decisions relating to convexity usage often without the clinical knowledge or practical experience to do so. Is it time that specialist nurses developed some best practice guidelines to ensure stoma care patients receive optimum care? AIM: To explore the need for nursing protocols that can be used to guide best practice when using convex appliances. METHOD: A pilot study was conducted in the form of a questionnaire. The questionnaire comprised numerous questions regarding current stoma care nursing (SCN) practice pertaining to the use of convex appliances. It was sent to 24 stoma care nurses, within both primary and acute care settings in the United Kingdom. RESULTS: Fifty-four percent response rate. The pilot study highlighted some interesting variations in current SCN practice. Reassuringly, 100% of respondents stated that convex appliance usage was primarily governed by the depth/degree of retraction. However, all those asked were practicing stoma care nurses, so perhaps the result may have been different if nonspecialist nurses had been asked? Eighty-five percent of stoma care nurses would opt for soft convex postoperatively initially if patients were experiencing problems with leaks; 77% prefer to use a cut-to-fit convex appliance as “not all stomas are round, sometimes need to adapt size and shape continually! CONCLUSION: This small pilot study highlighted some interesting and thought-provoking issues when reviewing stoma care nurses' usage of convex appliances. The study should be replicated on a much larger scale to facilitate the development of best practice guidelines for the use of convex products.

Boyd K, Thompson M, Boyd-Carson W, Trainor B. Use of convex appliances. Nurs Stand. 2004;18(20):37–38.

Buckle N. The dilemma of choice: introduction to a stoma assessment tool. Gastrointest Nurs. 2013; 11(4). doi:

Bourke R, Davis E, Dunne S, et al Making Sense of Convexity. Libertyville, IL: Hollister Inc; 2006.

Cronin E. A guide to the appropriate use of convex stoma care products. Gastrointest Nurs. 2008;6(2):12–16.

Ostomy—Stomal/Peristomal Complications



Charu Taneja, MPH, , Aaron Moynahan, MA, , and Gerry Oster, PhD, , Brookline, MA; Deanna Eaves, , Libertyville, IL; and Michael Riemer, MS, , Global Clinical Affairs, Libertyville, IL

OBJECTIVE: To estimate the risk and economic burden of peristomal skin complications (PSCs) in patients with recent ostomies in a large US integrated healthcare system. METHODS: We retrospectively identified 168 patients who underwent colostomy (ICD-9-CM 46.1X), ileostomy (46.2X), cutaneous uretero-ileostomy (56.5X), or other external urinary diversion (56.6X) between January 2012 and December 2014, using administrative data stores. Among these patients, we then identified those subjects who developed PSCs within 90 days of their surgery, based on medical record review. Using administrative data stores again, we compared levels of healthcare utilization and costs over 120 days, beginning with the date of surgery, between patients with evidence of PSCs and those without evidence of PSCs. Analyses of study data were descriptive in nature.

RESULTS: Sixty-one patients (36.3%) had evidence of PSCs in the 90-day period following surgery, including 47.5% of ileostomy patients, 36.1% of colostomy patients, and 15.0% of urinary diversion patients. Mean (SD) time from surgery to first notation of a PSC was 26.4 (19.0) days, ranging from 24.1 (13.2) days for ileostomy to 27.2 (21.1) days for colostomy and 31.7 (25.7) days for urinary diversion. Patients with PSCs were more likely to be readmitted to hospital within the 120-day observation period (55.7% vs 35.5% among those without PSCs) and have longer stays in hospital (mean, 11.0 days vs 6.8 days, respectively). Total healthcare costs over this period were almost $7500 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 surgery, associated with a higher incidence of rehospitalization and higher costs of care.

Continence—Evidence-Based Treatment and Management



Sarah Jackson, MPharmSci, , Jodie Lovett, MEng, , and Christian Stephenson, BSc, , Research and Development, Knutsford, Cheshire, United Kingdom; and Andrew Marxen, BAN, RN, CWON, CWS, MBA, , Doylestown, PA

Zinc oxide barrier creams are widely used to prevent and heal skin irritation. Traditional zinc oxide creams can be messy to use, with thick layer of cream required in order to provide protection to the skin. Recently, spray-on products have been developed, where much less is needed to provide skin protection. The aim of this experiment was to assess the protection against moisture provided by a zinc oxide spray versus a tubed product. Three 1 × 2-in areas were marked on the inner arm of 3 volunteers. These were labeled A, B, and control. A skin moisture meter was used to assess the hydration of the skin in each area for 10 replicates; 0.01 oz of each of the products was applied to areas A and B. The control area was left untreated, with no cream applied. The products were left in place for 1 hour and then a towel soaked with water applied to the arm for 30 minutes. This was resoaked every 5 minutes to simulate a moisture challenge. After 30 minutes, hydration of the skin in each area was reassessed. Hydration of the skin under each of the barrier creams was compared to hydration at the control area. This was used to calculate the percentage effectiveness for each of the barrier products. It was found that the spray product offered improvements of 50%, 55%, and 62% in moisture protection over the control area in volunteers 1, 2, and 3, respectively, with a small variation in efficacy between patients. The tubed product provided a much wider variation in protection, showing improvements of 15%, 3%, and 30% on volunteers 1, 2, and 3, respectively. This study has shown that the efficacy of barrier products displays variation between volunteers. With a vast number of options on the market, this highlights the importance of product selection.

Wound—Product Selection and Innovations



Jodie Lovett, MEng, , Sarah Jackson, MPharmSci, , and Christian Stephenson, BSc, , Research and Development, Knutsford, Cheshire, United Kingdom; and Andrew Marxen, BAN, MBA, RN, CWON, CWS, , Doylestown, PA

INTRODUCTION: Gelling dressings used to pack cavity wounds must be able to be removed in 1 piece. Clinicians are presented with laboratory data for strength; however, there is little evidence to dictate what value is sufficient for 1-piece removal from a cavity wound. To understand the relationship between numerical and practical data, the strength of 8 ribbon dressings was assessed quantitatively, using a tensiometer, and qualitatively, using a porcine (pork) cavity model. METHOD: Tensile strength was determined by using a tensiometer to measure the force required to break the ribbon, for both wet and dry products. Simulated “cavity wounds” (0.8-in diameter × 2-in deep) were created in pork, each filled with 3 mL of simulated wound fluid. Ribbons (N = 3) were applied and assessed over 3 days. Fluid was added each day to simulate wound exudate. On day 3, ribbons were removed and product integrity was noted. The test was repeated using cavities with slit wound entry (1-in long and 1.5-in deep) to provide an increased challenge to the dressings. Fluid input was adjusted accordingly to the wound size. RESULTS: Tensiometer data: Tensile strength varied between dressings, with some demonstrating high strength and others relatively low. Pork cavity model, large: Fluid handling varied. Pooling was noted in dressings B, E, and F. Dressing D leaked. Each ribbon was removed from the cavity in 1 piece, although dressing C partially tore and others left fibers in the cavity. Small cavities: All dressings handled the fluid supplied. One dressing tore completely on removal, with all others allowing for intact removal on day 3 even when resistance to removal was noted. CONCLUSION: Nearly all ribbons performed effectively in this clinically relevant pork cavity wound model, even ribbons with relatively low tensile strength. With the varying numerical values, this suggests that numerical strength may not translate into clinical efficacy.



Helen Thomason, PhD, , Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom; David Warde, PhD, , and Christian Stephenson, BSc, , Research and Development, Knutsford, Cheshire, United Kingdom; Andrew McBain, PhD, , School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, United Kingdom; and Karen Cuvelier, PEng, , and Michelle Woodward, BSc, , Edmonton, AL

INTRODUCTION: Ionic silver (Ag1+) is an effective antimicrobial agent and long been used for the treatment of infected wounds through incorporation into dressings. Dressings containing silver oxysalts, which release higher oxidative states of silver (Ag1+,2+,3+), have recently been developed. Here, we compared the effectiveness of dressings containing Ag1+ or silver oxysalts against a broad spectrum of bacteria and biofilms. METHODS: Efficacy of gelling fiber dressings containing Ag1+ or silver oxysalts was assessed in log reduction studies against 3 gram-negative and gram-positive bacteria over 7 days with daily reinoculation. Efficacy of silver oxysalts over 14 days was also assessed in daily reinoculated log reduction assays. To determine the effects of Ag1+ and silver oxysalts on biofilms, Pseudomonas aeruginosa biofilms were cultured for 3 days before applying to porcine skin cultured ex vivo for a further 24 hours. Dressings were applied to the mature biofilms for 24 hours, after which biofilms were assessed using a viability dye and scanning electron microscopy (SEM). RESULTS: Over 7 days, dressings containing silver oxysalts exhibited significantly greater log reductions (5-7 log) compared to Ag1+ (3-6 log) dressings. In addition, silver oxysalts dressings maintained more than 5 log reductions for 14 days with daily reinoculation of Staphylococcus aureus or P aeruginosa. Viability staining and SEM revealed a greater effect against mature P aeruginosa biofilms with silver oxysalts dressings compared to Ag1+ dressings. The higher oxidative states of silver disrupted the biofilm to reveal underlying porcine collagen fibers that were not evident with Ag1+ treatment. CONCLUSION: The potent nature of silver oxysalts results in rapid and sustained log reductions against a broad spectrum of bacteria. Furthermore, these high oxidative states of silver effectively disrupt mature biofilms. The strong attraction for electrons of higher oxidative states of silver therefore makes Ag oxysalts more effective against microbes.



Gary Delhougne, JD, MHA, , and Kim Tarka, BA, , Fort Worth, TX; Christopher Hogan, PhD, , Vienna, VA; and Sunitha Nair, MD, FACPWA, , Evanston, IL

BACKGROUND: Negative pressure wound therapy (NPWT) has been shown to facilitate wound closure, reduce wound complications, and reduce the number of dressing changes compared to standard wound care. As the use of traditional NPWT (tNPWT) increased, costs to Centers for Medicare & Medicaid Services (CMS) also increased. From 2001 to 2007, payments for tNPWT increased from $24 million to $164 million. Disposable NPWT (dNPWT) has been shown to deliver equivalent outcomes compared to tNPWT. We compared the costs and treatment episode lengths associated with tNPWT and dNPWT in patients requiring NPWT. METHODS: NPWT patient data were extracted from the 2012-2014 CMS Limited Data Set Standard Analytic File (LDS SAF) and divided into 2 mutually exclusive groups: patients who received tNPWT and patients who received dNPWT. Each NPWT episode was initiated by a CMS claim for an NPWT device and continued until there was a break of more than 31 days between claims. NPWT episode length was calculated as the average interval between device claims; for episodes with only 1 NPWT device, episode length was based on the average interval for all patients with NPWT. NPWT costs were defined as CMS payments (US 2013 dollars) for NPWT supplies and services. RESULTS: In total, 2938 patients received tNPWT and 3522 received dNPWT. The average cost per tNPWT episodes was $4650 versus $1532 for dNPWT. Mean length of tNPWT episode was 43.3 days versus 28.3 days for dNPWT. Sensitivity analyses demonstrated that cost savings were not impacted by wound or comorbidity characteristics but were reduced modestly when repriced at 2016 rates. CONCLUSION: The cost of dNPWT is one-third the cost of tNPWT. Given the incidence of NPWT use in the United States, we estimate that CMS could realize costs savings of more than $1 billion over a 10-year period if patients use dNPWT over tNPWT for wound care.

Author Index to Abstracts

© 2017 by the Wound, Ostomy and Continence Nurses Society.