A Selection of Ten Readings on Topics Related to Wound Care

BACKGROUND: Accurate pressure ulcer staging is an important skill for nurses, physicians, physical therapists, and certi ed nursing assistants. Current education is based on the National Pressure Ulcer Advisory Panel's staging system. A review of the literature indicates variability in staging abilities of numerous healthcare providers. With this problem in mind, a new method of teaching pressure ulcer staging by visual analogy was developed. METHODS: We used the current National Pressure Ulcer Advisory Panel de nitions to create a training tool based on a visual analogy between the di erent pressure ulcer stages and common fruits and vegetables. RESULTS: Initial feedback from a western states wound care conference indicates successful integration of teaching into nursing practice. A poster was also presented at the annual 2011 Wound, Ostomy and Continence Nurse's National Conference. Positive feedback was received from numerous Wound, Ostomy and Continence Nurse's members who requested an electronic copy of the poster. CONCLUSIONS: Visual analogies can provide a method of teaching pressure ulcer staging across di erent disciplines with di erent levels of training involved in patient care. Mackintosh R, Gwilliam A, Williams M. Teaching the fruits of pressure ulcer staging. J Wound Ostomy Continence Nurs. 2014 Jul-Aug;41(4):381-7. PubMed PMID: 24988517 READING 2 – NUTRITIONAL STRATEGIES TO REDUCE PRESSURE ULCERS URL: http://www-ncbi-nlm-nih-gov /pubmed?term=23426414&report=abstract&format=text – free full text Author information: (1)MEP Healthcare Dietary Services, Inc, Evansville, Indiana, USA. Comment in Adv Skin Wound Care. 2013 Mar;26(3):102. e objectives of this continuing education article are to analyze the aging process and its e ect on the nutritional status of frail older adults; determine how sarcopenia, anorexia, malnutrition, and Alzheimer disease increase the risk for pressure ulcer development and impact the healing process; and to apply evidence-based nutrition guidelines and implement practical solutions for wound healing. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 0(3) J U L Y S E P T E M B E R 2 0 1 4 : 35 Posthauer ME, Collins N, Dorner B, Sloan C. Nutritional strategies for frail older adults. Adv Skin Wound Care. 2013 Mar;26(3):128-40; quiz 141-2. doi: 10.1097/01.ASW.0000427920.74379.8c. PubMed PMID: 23426414. READING 3 – PRESSURE RISK MANAGEMENT GUIDELINES WORK URL: http://onlinelibrary.wiley.com./doi/10.1111/j.1365-2753.2012.01870.x/pdf Payment required ABSTRACT RATIONALE: is paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia.RATIONALE: is paper reports an initiative which promoted evidence-based practice in pressure risk assessment and management among home nursing clients in Melbourne, Australia. AIM AND OBJECTIVES: e aim of this study was to evaluate the introduction and uptake of the Australian Wound Management Association Guidelines for the Prediction and Prevention of Pressure Ulcers. METHOD: In 2007 a pilot study was conducted. Nurse perspectives (n=21) were obtained via survey and a client pro le (n=218) was generated. Audit of the uptake and continued use of the pressure risk screening tool, during the pilot study and later once implemented as standard practice organizational wide, was conducted. RESULTS: Nurses at the pilot site successfully implemented the practice guidelines, pressure risk screening was adopted and supporting resources were well received. Most clients were at low risk of pressure ulcer development. e pilot site maintained and extended their pilot study success, ensuring more than 90% of clients were screened for pressure risk over the 18 months which followed. All other sites performed less well initially, however subsequently improved, meeting the pilot sites success after 18 months. Two years later, the organization continues to screen more than 90% of all clients for pressure risk. CONCLUSION: Implementation of clinical practice guidelines was successful in the pilot project and pressure risk screening became a well-adopted practice. Success continued following organizational wide implementation. Pilot study ndings suggest it may be prudent to monitor the pressure ulcer risk status of low risk clients so as to prevent increasing risk and pressure ulcer development among this group. © 2012 John Wiley & Sons Ltd. READING 4 – REPOSITIONING FOR PRESSURE ULCER PREVENTION URL: http://onlinelibrary.wiley.com./doi/10.1002/14651858.CD009958.pub2/pdf -Payment required Author information: (1)NHMRC Centre of Research Excellence in Nursing, Gri th University, Brisbane, Queensland, Australia. A SELECTION OF TEN READINGS ON TOPICS RELATED TO WOUND CARE compared with alternate schedules or standard practice. SEARCH METHODS: We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to 30 August 2013); and the reference sections of studies that were included in the review. SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, that assessed the e ects of any repositioning schedule or di erent patient positions and measured PU incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS: We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30o and 90o tilt positions using similar repositioning frequencies (there was a small di erence in frequency of overnight repositioning in the 90o tilt groups between the trials). e third RCT compared alternative repositioning frequencies. All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias. e two trials of 30o tilt vs. 90o were pooled using a random e ects model (I2 = 69%) (252 participants). e risk ratio for developing a PU in the 30o tilt and the standard 90o position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). is comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. is study was also underpowered and at high risk of bias. e risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). e risk ratio for pressure ulcers (any category) was compatible with a large reduction and no di erence between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-e ectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30o tilt overnight with standard care consisting of 6-hourly repositioning using the 90o lateral rotation overnight. In this evaluation the only included cost was nursing time. e intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental di erence €-46.5; 95%CI: €-1.25 to €-74.60). AUTHORS' CONCLUSIONS: Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely recommended and used in practice. e lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ine ective since all comparisons are grossly underpowered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30° tilt compared with the standard 90o position or good evidence of an e ect of repositioning frequency. ere is a clear need for high-quality, adequately-powered trials to assess the e ects of position and optimal frequency of repositioning on pressure ulcer incidence. e limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30o tilt is less costly in terms of nursing time and more e ective than standard care involving repositioning every 6 hours using a 90o tilt. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 0(3) J U L Y S E P T E M B E R 2 0 1 4 : 36 ABSTRACT BACKGROUND: A pressure ulcer (PU), also referred to as a 'pressure injury', 'pressure sore', or 'bedsore' is de ned as an area of localised tissue damage that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are elderly and less mobile, and carry signi cant human and economic impacts. Immobility and physical inactivity are considered to be major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure ulcer prevention strategy. OBJECTIVES: e objectives of this review were to:1) assess the e ects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most e ective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing di erent repositioning regimens Kapp S. Successful implementation of clinical practice guidelines for pressure risk management in a home nursing setting. J Eval Clin Pract. 2013 Oct;19(5):895-901. doi: 10.1111/j.1365-2753.2012.01870.x. Epub 2012 Jun 5. PubMed PMID: 22672390. Author information: Research Fellow, Registered Nurse, Royal District Nursing Service Helen Macpherson Smith Institute of Community Health, St Kilda, Victoria, Australia. Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014 Apr 3;4:CD009958. doi: 10.1002/14651858.CD009958.pub2. PubMed PMID: 24700291. compared with alternate schedules or standard practice. SEARCH METHODS: We searched the following electronic databases to identify reports of the relevant randomised controlled trials: the Cochrane Wounds Group Specialised Register (searched 06 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); Ovid MEDLINE (1948 to August, Week 4, 2013); Ovid EMBASE (1974 to 2013, Week 35); EBESCO CINAHL (1982 to 30 August 2013); and the reference sections of studies that were included in the review. SELECTION CRITERIA: Randomised controlled trials (RCTs), published or unpublished, that assessed the e ects of any repositioning schedule or di erent patient positions and measured PU incidence in adults in any setting. DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS: We included three RCTs and one economic study representing a total of 502 randomised participants from acute and long-term care settings. Two trials compared the 30o and 90o tilt positions using similar repositioning frequencies (there was a small di erence in frequency of overnight repositioning in the 90o tilt groups between the trials). e third RCT compared alternative repositioning frequencies. All three studies reported the proportion of patients developing PU of any grade, stage or category. None of the trials reported on pain, or quality of life, and only one reported on cost. All three trials were at high risk of bias. e two trials of 30o tilt vs. 90o were pooled using a random e ects model (I2 = 69%) (252 participants). e risk ratio for developing a PU in the 30o tilt and the standard 90o position was very imprecise (pooled RR 0.62, 95% CI 0.10 to 3.97, P=0.62, very low quality evidence). is comparison is underpowered and at risk of a Type 2 error (only 21 events).In the third study, a cluster randomised trial, participants were randomised between 2-hourly and 3-hourly repositioning on standard hospital mattresses and 4 hourly and 6 hourly repositioning on viscoelastic foam mattresses. is study was also underpowered and at high risk of bias. e risk ratio for pressure ulcers (any category) with 2-hourly repositioning compared with 3-hourly repositioning on a standard mattress was imprecise (RR 0.90, 95% CI 0.69 to 1.16, very low quality evidence). e risk ratio for pressure ulcers (any category) was compatible with a large reduction and no di erence between 4-hourly repositioning and 6-hourly repositioning on viscoelastic foam (RR 0.73, 95% CI 0.53 to 1.02, very low quality evidence).A cost-e ectiveness analysis based on data derived from one of the included parallel RCTs compared 3-hourly repositioning using the 30o tilt overnight with standard care consisting of 6-hourly repositioning using the 90o lateral rotation overnight. In this evaluation the only included cost was nursing time. e intervention was reported to be cost saving compared with standard care (nurse time cost per patient €206.6 vs €253.1, incremental di erence €-46.5; 95%CI: €-1.25 to €-74.60). AUTHORS' CONCLUSIONS: Repositioning is an integral component of pressure ulcer prevention and treatment; it has a sound theoretical rationale, and is widely recommended and used in practice. e lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ine ective since all comparisons are grossly underpowered. Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30° tilt compared with the standard 90o position or good evidence of an e ect of repositioning frequency. ere is a clear need for high-quality, adequately-powered trials to assess the e ects of position and optimal frequency of repositioning on pressure ulcer incidence. e limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30o tilt is less costly in terms of nursing time and more e ective than standard care involving repositioning every 6 hours using a 90o tilt. A SELECTION OF TEN READINGS ON TOPICS RELATED TO WOUND CARE READING 5 – COMPARING PRESSURE ULCER TREATMENT STRATEGIES URL: http://www-ncbi-nlm-nih-gov /pubmedhealth/PMH0057472 – Free full text Author information: (1) Oregon Evidence-based Practice Center, Oregon Health & Science University, Portland, OR 97239-3098, USA. [email protected] Smith ME, Totten A, Hickam DH, Fu R, Wasson N, Rahman B, Motu'apuaka M, Saha S. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013 Jul 2;159(1):39-50. doi: 10.7326/0003-4819-159-1-201307020-00007. Review. PubMed PMID: 23817703. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 0(3) J U L Y S E P T E M B E R 2 0 1 4 : 37 ABSTRACT BACKGROUND: A pressure ulcer (PU), also referred to as a 'pressure injury', 'pressure sore', or 'bedsore' is de ned as an area of localised tissue damage that is caused by unrelieved pressure, friction or shearing forces on any part of the body. PUs commonly occur in patients who are elderly and less mobile, and carry signi cant human and economic impacts. Immobility and physical inactivity are considered to be major risk factors for PU development and the manual repositioning of patients in hospital or long-term care is a common pressure ulcer prevention strategy. OBJECTIVES: e objectives of this review were to:1) assess the e ects of repositioning on the prevention of PUs in adults, regardless of risk or in-patient setting;2) ascertain the most e ective repositioning schedules for preventing PUs in adults; and3) ascertain the incremental resource consequences and costs associated with implementing di erent repositioning regimens ABSTRACT BACKGROUND: Pressure ulcers a ect as many as 3 million Americans and are major sources of morbidity, mortality, and health care costs. PURPOSE: To summarize evidence comparing the e ectiveness and safety of treatment strategies for adults with pressure ulcers. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of E ects, and Health Technology Assessment Database for Englishor foreign-language studies; reference lists; gray literature; and individual product packets from manufacturers (January 1985 to October 2012). STUDY SELECTION: Randomized trials and comparative observational studies of treatments for pressure ulcers in adults and noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms. DATA EXTRACTION: Data were extracted and evaluated for accuracy of the extraction, quality of included studies, and strength of evidence. DATA SYNTHESIS: 174 studies met inclusion criteria and 92 evaluated complete wound healing. In comparison with standard care, placebo, or sham interventions, moderate-strength evidence showed that airuidized beds (5 studies [n = 908]; high consistency), protein-containing nutritional supplements (12 studies [n = 562]; high consistency), radiant heat dressings (4 studies [n = 160]; moderate consistency), and electrical stimulation (9 studies [n = 397]; moderate consistency) improved healing of pressure ulcers. Low-strength evidence showed that alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy improved healing of pressure ulcers. e evidence about harms was limited. LIMITATION: Applicability of results is limited by study quality, heterogeneity in methods and outcomes, and inadequate duration to assess complete wound healing. CONCLUSION: Moderate-strength evidence shows that healing of pressure ulcers in adults is improved with the use of airuidized beds, protein supplementation, radiant heat dressings, and electrical stimulation.BACKGROUND: Pressure ulcers a ect as many as 3 million Americans and are major sources of morbidity, mortality, and health care costs. PURPOSE: To summarize evidence comparing the e ectiveness and safety of treatment strategies for adults with pressure ulcers. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of E ects, and Health Technology Assessment Database for Englishor foreign-language studies; reference lists; gray literature; and individual product packets from manufacturers (January 1985 to October 2012). STUDY SELECTION: Randomized trials and comparative observational studies of treatments for pressure ulcers in adults and noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms. DATA EXTRACTION: Data were extracted and evaluated for accuracy of the extraction, quality of included studies, and strength of evidence. DATA SYNTHESIS: 174 studies met inclusion criteria and 92 evaluated complete wound healing. In comparison with standard care, placebo, or sham interventions, moderate-strength evidence showed that airuidized beds (5 studies [n = 908]; high consistency), protein-containing nutritional supplements (12 studies [n = 562]; high consistency), radiant heat dressings (4 studies [n = 160]; moderate consistency), and electrical stimulation (9 studies [n = 397]; moderate consistency) improved healing of pressure ulcers. Low-strength evidence showed that alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy improved healing of pressure ulcers. e evidence about harms was limited. LIMITATION: Applicability of results is limited by study quality, heterogeneity in methods and outcomes, and inadequate duration to assess complete wound healing. CONCLUSION: Moderate-strength evidence shows that healing of pressure ulcers in adults is improved with the use of airuidized beds, protein supplementation, radiant heat dressings, and electrical stimulation. T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 0(3) J U L Y S E P T E M B E R 2 0 1 4 : 38 A SELECTION OF TEN READINGS ON TOPICS RELATED TO WOUND CARE READING 6 – ENZYMATIC SUPERIOR TO AUTOLYTIC DEBRIDEMENT URL: http://informahealthcare.com. /doi/pdf/10.3111/13696998.2013.807268 – Free full text Author information: (1)Healthpoint Biotherapeutics, Fort Worth, TX 76107, USA. [email protected] ABSTRACT OBJECTIVE: e purpose of this study was to determine the cost-e ectiveness of enzymatic debridement using collagenase relative to autolytic debridement with a hydrogel dressing for the treatment of pressure ulcers. METHODS: A 3-stage Markov model was used to determine the expected costs and outcomes of wound care for collagenase and hydrogel dressings. Outcome data used in the analysis were taken from a randomized clinical trial that directly compared collagenase and hydrogel dressings. e primary outcome in the clinical trial was the proportion of patients achieving a closed epithelialized wound. Transition probabilities for the Markov states were estimated from the clinical trial. A 1-year time horizon was used to determine the expected number of closed wound days and the expected costs for the two alternative debridement therapies. Resource utilization was based on the wound care treatment regimen used in the clinical trial. Resource costs were derived from standard cost references and medical supply wholesalers. e economic perspective taken was that of the long-term care facility. No cost discounting was performed due to the short time horizon of the analysis. A deterministic sensitivity analysis was conducted to analyze economic uncertainty. Waycaster C, Milne CT. Clinical and economic benefit of enzymatic debridement of pressure ulcers compared to autolytic debridement with a hydrogel dressing. J Med Econ. 2013 Jul;16(7):976-86. doi: 10.3111/13696998.2013.807268. Epub 2013 Jun 7. PubMed PMID: 23701261.