In This Issue of JWOCN

This issue provides follow-up to ongoing issues in acute care facilities, including hospital-acquired pressure ulcers and catheter-associated urinary tract infections, and it introduces important new knowledge about distant wound care consults, use of acoustic pressure wound therapy, wound-associated pain, selecting among negative-pressure wound therapies, urinary leg bags, and knowledge about urinary incontinence among Korean American women.

This issue also includes important contributions to an ongoing topic of discussion that has spread from specialists such as WOC nurses to the healthcare community at large: "How do we effectively prevent the 'Big 8?'" While this issue affects all healthcare professionals practicing in acute care, 2 of the conditions, hospital-acquired pressure ulcers and catheter-associated urinary tract infections, are of special interest to WOC nurses. The WOCN Clinical Practice Continence Sub-Committee, chaired by Diana Parker working with Laurie Callan, Judith Harwood, Donna Thompson, Marilyn-Lu Webb, Mary Wilde, and Margaret Willson, has completed a Catheter Associated Urinary Tract Infection Fact Sheet that provides succinct and cogent facts about the epidemiology and etiology of the most common hospital-acquired infection encountered in the United States, as well as its diagnosis, prevention, and treatment. This document is considered so significant that it was Posted Ahead of Print (PAP) in order to make it available to WOCN members as soon as possible. Continue to look for PAP articles from the Journal; we are proud to make this novel option available to our readers as we strive to bring you the latest clinical insights and evidence relevant to your practice. In addition to the Fact Sheet, members of the Continence Sub-Committee and the Journal's editorial office have published Part 2 of the Evidence Based Report Card, reviewing current evidence for prevention of catheter-associated urinary tract infections. This document answers 10 clinically relevant questions about prevention, novel strategies for prevention, and revealing surprising findings about traditional interventions such as use of sterile technique for insertion, bladder irrigation, and frequency of catheter changes when managing long-term catheters. Heather Orsted, Sue Rosenthal, and Gail Woodbury describe a pressure ulcer awareness and prevention program promulgated by the Canadian Association of Wound Care. This article describes a national program that incorporates innovative approaches to pressure ulcer prevention in long-term care facilities. Whether you practice in acute or long-term care, this article contains must-read insights into effective methods for translating knowledge about prevention into an effective program that alters awareness of facility-acquired pressure ulcers and enables sustainable adherence to effective prevention strategies.

Eileen Harwood and Elizabeth Hutchinson follow up on their ongoing how-to series about collecting data for research studies. Despite all the steeped language, they demonstrate that a well-designed research protocol can be compared to a good recipe. It provides step-by-step directions that guide the clinician through a process of measuring outcomes to a clinically relevant question. Whether you are a researcher or simply someone interested in understanding what all the research-related fuss is about, this article is a must read because it not only humanizes the research process but also uses examples from the Journal of Wound, Ostomy and Continence Nursing-your journal about your specialty practice-to help the novice investigator to design a research study and the consumer to understand the pragmatic steps required to meaningfully answer the questions raised on our discussion forums on a daily basis.

Jane Fellows continues our feature focusing on getting ready for certification with 3 sample questions about ostomy care. Read this regular feature of the Journal to improve your understanding of how the WOCNCB constructs questions to test knowledge and how you can successfully acquire or renew your credentials in wound, ostomy and continence care.

Kathleen Buckley, Linda Kock Adelson, and Jane Agazio report a study of the significance of adding digital images to verbal reports when consulting with a wound care specialist, a WOC nurse. Although the verbal report has long been considered the gold standard for communicating assessment data over distance, advances in technology that have revolutionized radiology practice also hold the potential to forever change the way we assess multiple areas of the body, including the skin. Read this study to gain insights into how digital images confirmed the verbal report in some cases, enhanced the report in many others, and changed or modified the diagnosis and subsequent plan of care in a significant portion of patients.

Noncontact, low-frequency ultrasound therapy is a novel approach to debride and promote healing a variety of acute and chronic wounds. Pamela Cole, Jennifer Quisberg, and Mark Melin report on adjuvant use of acoustic pressure therapy for treatment of chronic wounds. Does this technology have a potential role in your practice? You will want to read this article, which summarizes their experiences with 41 patients and 52 wounds over a 1-year period and decide for yourself.

A skillfully constructed conceptual model combines a variety of complicated issues into a small group of principles that guide practice, especially among the most complicated patients. In this issue's Continuing Education feature article, Kevin Woo and Gary Sibbald propose a conceptual model for managing painful wounds called WAP (Wound Associated Pain). These authors have experience with the development and popularization of another model for wound care, TIME,1 that combines concepts about wound bed preparation into a rational and comprehensible framework. You will want to read this article describing a model that addresses an issue central to all WOC and nursing management of wounds, pain relief and prevention.

This issue's Continence Care section opens with yet another article demonstrating the complexity of care when delivered to an ever-growing number of persons with diverse ethnic and cultural backgrounds. Youngmi Kang summarizes knowledge about urinary incontinence among Korean American women. You will want to read this article to gain knowledge about an important and understudied group and to understand what you can do to more effectively treat incontinence in your patient population.

Your Clinical Challenges feature article is designed to promote critical thinking and to encourage innovative care beyond that supported by robust clinical evidence. Experienced WOC nurses will immediately appreciate that this describes a significant portion (and perhaps the majority) of our practice. Mary Arnold Long and Anne Blevins provide an excellent example of critical thinking in their article, Options in Negative Pressure Therapy: Five Case Studies. This is a must read article for any WOC nurse who has used any of the negative pressure systems, not because it merely describes the various systems and their potential applications, but to see how Long and Blevins use a process of critical thinking to go beyond claims that "product X" is better than "brand Y" to an approach that uses multiple forms of therapy based on individualized assessment of the patient and wound care needs.

Evidence From Other Publications

WOUND CARE

Acute care facilities continue to grapple with ongoing demands from patients, families, and reimbursement agencies to prevent hospital-acquired infections. Multiple articles in this and previous issues of the Journal illustrate how WOC nurses contribute to this worthwhile goal, but have you ever considered use of a skin sealant in order to prevent surgical site infection? One hundred seventy-seven adults undergoing inguinal hernia repair were randomly assigned to skin preparation with a 10% povidone-iodine solution alone or skin preparation followed by application of an acrylate-based liquid microbial sealant.2 Study outcomes were the effect of the skin sealant on bacteriologic load at the surgical site, and the incidence of surgical site infections measured as a secondary outcome. Subjects treated with the acrylate sealant were significantly less likely to have bacterial cells in their wounds than were those treated with the povidone-iodine preparation only. Three subjects developed surgical site infections; all were in the group treated with povidone-iodine preparation alone. However, this difference was not statistically significant. Although additional research is needed to confirm or refute these findings, this study suggests that application of a skin sealant may reduce the risk of abdominal surgical site infection.

OSTOMY CARE

The frequency, diagnosis, prevention, and management of stomal and peristomal complications has generated a good deal of discussion in both the professional literature and WOCN forum. Most of the discussion has focused on immediate postoperative and early complications, but considerably less is known about the frequency and characteristics of late complications. A recent issue of Diseases of the Colon and Rectum included a case report and literature review of primary adenocarcinoma in a permanent ileostomy.3 The case involved a 66-year-old woman with an ileostomy for almost 60 years owing to inflammatory bowel disease. Physical examination revealed a 3-to 4-cm area of indurate granulation tissue, later confirmed to be a primary adenocarcinoma on biopsy. Although a rare complication of permanent ileostomies, adenocarcinomas tend to occur 27 years or more after ostomy surgery. Based on a comprehensive literature review, the authors note that the most common presentation is a friable mass that bleeds easily and shows difficulty with pouching or signs and symptoms of intestinal obstruction. Lymph node metastasis was noted in 19% of cases documented in the literature, but the reported survival rate is approximately 85%. As with most malignancies, prompt diagnosis and early, aggressive treatment are keys to survival. This case study is one reminder of the significance of long-term WOC nurse education and follow-up for all patients with permanent ostomies and the significance of learning more about patients with longstanding ostomies.

CONTINENCE CARE

Continence nurses traditionally counsel patients that incontinence is not an inevitable part of aging. However, the progression of benign prostatic hyperplasia and associated lower urinary tract symptoms have been so closely associated with aging that clinicians tend to tacitly assume that these conditions are an inevitable aspect of aging rather than the result of modifiable factors such as diet or physical activity. However, a systematic review of 8 studies collectively involving more than 35,000 older men found that physical activity reduces the risk of benign prostatic enlargement and associated lower urinary tract symptoms.4 When compared to men who were sedentary, the pooled odds ratios for a man developing benign prostatic enlargement or lower urinary tract symptoms were 0.70 to 0.74 for men who engaged in light, moderate, or heavy physical activity. Since odds ratios less than 1 indicate a protective effect, these statistics provide evidence that WOC nurses can also counsel men that the bothersome lower urinary tract symptoms and associated prostatic enlargement are not inevitable aspects of aging. Instead, maintenance of physical activity will reduce the risk of developing these conditions and promote heart and bone health.

References