In This Issue of JWOCN

This issue of the Journal opens with a White Paper from the Wound, Ostomy and Continence Nurses Society that impacts everyone's practice. This document qualifies as must read for every WOC nurse, including the newly certificated CWOCN, CWON, CWCN, COCN, and CCCN to the growing group of WOC nurses with advanced practice credentials as nurse practitioners and clinical nurse specialists. As you read this article, I recommend reflecting on the following historical truths about our specialty practice. WOC is one of a small cadre of unique nursing specialty practices; there is no analogous specialty practice in medicine or physical therapy. Although official recognition of WOC nursing as a specialty practice area from the ANA is comparatively recent, our specialty practice proudly traces its origins to the 1950s. While WOC nursing is practiced at the baccalaureate level and higher, the team that supports our practice continues to grow and includes a variety of care givers including staff nurse colleagues, nursing assistants, and licensed practical nurses.

This issue's Wound Care section opens with a meta-analysis of diabetes mellitus as a risk factor for surgery-related pressure ulcers. Peng Liu, Wei He, and Hong-Lin Chen extracted data from 6 studies to evaluate the magnitude of risk for surgery-related pressure ulceration in patients with diabetes mellitus as compared to patients with normal glucose tolerance. You will want to read this article to learn more about the association significant role that diabetes mellitus plays in pressure ulcer risk in this acutely vulnerable population.

Elizabeth I. Helvig and Lynn Wemett Nichols report the predictive power of high-frequency ultrasound for predicting heel pressure ulcer development in at-risk patients. This article qualifies as must read because it addresses a persistent need in our efforts to prevent and effectively manage pressure ulcers; can we find a physiologic variable that detects ischemic distress prior to irreversible tissue damage and formation of a visible pressure ulcer? You will want to read this article to evaluate the potential for high-frequency ultrasound in the detection of heel pressure ulcers prior to onset of visible skin damage.

Li Cong, Jiaohua Yu, and Yilan Liu report their initial experience before and after implementing a pressure ulcer prevention program in a 3000-bed teaching hospital in China. You will want to read this article to both appreciate the influence of emerging trends in the United States on a global basis and compare your efforts with the efforts of this wound care team functioning in a large health system in central China.

This issue's Clinical Challenges feature article also focuses on wound care. Lynda Allen, Barbara McGarrah, Deborah Barrett, Bethany Stenson, Patricia G. Turpin, and Catherine VanGilder report a case series of 10 patients with suspected deep tissue injuries. You will want to read this innovative case series to judge whether this preventive approach should be incorporated into your facility's pressure ulcer prevention program.

This issue's Ostomy Care Section opens with a report of findings from a multisite, randomized, controlled trial (RCT) authored by Carol Stott, Lisa Graaf, Patricia Morgan, Julia Kittscha, and Greg Fairbrother, which compared a standardized laxative regimen for managing constipation following colostomy surgery. You will want to read this research report to determine whether the laxative regimen evaluated in this ostomy nurse-driven RCT should be adapted to your postoperative ostomy patients.

Debra Crawford, Tracy Texter, Kristin Hurt, Randy VanAelst, Leslie Glaza and Karen Vander Laan report results of a second RCT, comparing traditional ostomy education in patients with newly formed fecal ostomies to a program enhanced with a DVD capable of implementation as a just-in-time education as patients and their families learn pouching skills and principles of ostomy management. This innovative RCT qualifies as must read because it provides insight into the potential for adapting just-in-time educational techniques to the considerable demands of postoperative ostomy education in patients with ever briefer hospital courses.

This issue's Ostomy Care section closes with a valuable Primer from Lynn Mohr, who reviews developmental issues faced by adolescents aged 12 to 18 years and their impact on the adolescent facing ostomy surgery. You will want to read this valuable article to review and sharpen your knowledge of this developmental phase and to complete the attached contact hours.

Your Continence Care section opens with an evaluation of the stopwatch urine stream interruption test. Joanne Robinson, Sherry Burell, Tamara Avi-Itzhak, and Ruth McCorkle compared results from 3 instruments-a 24-hour pad test, Broome Pelvic Muscle Self-Efficacy Scale, and 3-day bladder diary-to evaluate the convergent validity of the urine stream interruption test in men with urinary incontinence following radical prostatectomy. You will want to read this research report to gain insights into the potential for the test as an assessment tool for pelvic floor muscle strength.

Daniela Hayder reports a qualitative study that evaluated the influence of urinary incontinence on sexuality and intimate relationships. You will want to read this valuable research report to gain insights into the negative impact of urinary incontinence on sexual expression and to identify coping strategies used by incontinent individuals to reassert sexual intimacy and maintain intimate relationship despite this ongoing challenge.

This issue's Getting Ready for Certification includes a critical analysis of a wound care item that focuses on careful consideration of the study stem, distractors, and item answer. Donna Thompson and Kay Durkop-Scott followed this brief discussion with 3 practice items that show how these analytic skills can be applied to a successful certification or recertification experience.

In this issue's Spotlight on Research, Wound Care Section Editor Joy Pittman and her colleague Mary Sitterding define a practice innovation process, using a quality improvement model, and differentiate this process from classic research. This article qualifies as must read for any WOC nurse seeking to improve local practice patterns based on the latest evidence-based knowledge and to differentiate this process from the more tightly regulated process of clinical research.

Evidence From Other Publications

When is a chronic wound infected? This seemingly simple question reveals a surprising lack of knowledge about the influence of bacterial colonization on wound healing, the impact of attempts to reduce bacterial load in the chronic wound, and ongoing controversy about how to quantify bacterial colonization. In 2012, JAMA published a systematic review of studies that evaluated signs and symptoms indicating possible chronic wound infection, laboratory, and radiographic markers.1 The 15 studies that met inclusion criteria enrolled 985 patients with 1056 chronic wounds. The prevalence of wounds deemed infected was 53%, clearly illustrating the clinical relevance of this common complication. However, the most important finding of this systematic review and meta-analysis was the lack of consistent evidence needed to define clear criteria for diagnosis of clinical infected chronic wound. The authors found that the only sign or symptom indicating an infection was an increase in the intensity of wound-associated pain (likelihood ratio range, 11-20). While the absence of pain did not exclude the presence of an infection, its absence was not as predictive as its presence. Clinical signs, including erythema, local heat, purulent exudate, and edema, were found to be poor predictors of underlying infection, which is consistent with overwhelming clinical experience in this area. One study included in this well-designed systematic review evaluated a combination of signs and symptoms (2 or more of the following: pain, erythema, induration, heat, and edema) for diagnosing infections in diabetic foot (neuropathic) ulcers. Unfortunately, reliance on a combination of 2 or more classic signs or symptoms of infection achieved a disappointing sensitivity of 52% and specificity of 46%. The authors performed a subanalysis of 4 studies that enrolled 198 patients and focused on noninvasive techniques for culturing wounds, including swabs cultures and various laboratory markers. Two techniques of obtaining a swab culture were compared to a reference standard (wound biopsy); they were the Z-technique where a swab is applied in a zigzag manner to the entire wound bed, and the Levine technique where a swab is rotated over a 1 x 1-cm area with sufficient force to extract fluid from within the wound bed. Analysis revealed that the Z-technique neither predicted nor excluded wound infection when compared to the reference standard. Obtaining a swab culture using the Levine technique was helpful in predicting an infection (likelihood ratio, 6.3; 95% confidence interval [CI]: 2.5-15). Similarly, obtaining a negative culture using the Levine technique reduced the likelihood of infection (likelihood ratio, 0.47; 95% CI: 0.31-0.73). These data clearly reflect the ongoing clinical debate concerning the true differential diagnosis of bacterial colonization, critical colonization, and infection in a chronic wound, its impact on wound healing, and its optimal management.

Ostomy Care

Mechanical bowel preparation remains a favored intervention prior to ostomy surgery in many facilities, but evidence of its efficacy for prevention of postoperative infection tells another story. In 2005, Colwell and Gray2 published an Evidence Based Report Card in the Journal of Wound, Ostomy and Continence Nursing, which queried whether mechanical bowel preparation reduces the risk of postoperative complications including infection. Based on a systematic review that included 10 studies, they concluded that mechanical bowel preparation provided no benefit when compared to no preparation. They also found a higher incidence of anastomotic leakage in patients undergoing mechanical bowel preparation, suggesting that the potential for harm from this intervention outweighed its potential benefit. In a recent multisite study, Serrurier and coworkers3 reported results of a retrospective study of 272 children who underwent colostomy takedown at 3 large health systems across the United States. Mechanical bowel preparation using polyethylene glycol was administered to 187 children. All of the children included in the review received perioperative antimicrobials, and 52% of those managed with mechanical bowel preparation also received oral antibiotics. Despite these additional precautions, the researchers found that mechanical bowel preparation offered no protection from postoperative complications. Rather, it was associated with an increased likelihood of postoperative surgical site infection, longer hospital length of stay. The findings of this study support the results reported by Colwell and Gray and reinforce evidence-based knowledge that mechanical bowel preparation not only fails to prevent postsurgical complications in children and adults undergoing colorectal surgery but paradoxically increases the risk for certain complications and increases hospital length of stay in children. It is past time to abandon this traditional preventive intervention based on the evidence that it is not only ineffective but paradoxically harmful to our patients.

Continence Care

A modest but growing body of evidence suggests that overactive bladder may be a lifelong condition for some patients. As a result, these patients are likely to experience lower urinary tract symptoms (LUTS) as a child, followed by slower mastery of continence and persistence of certain LUTS as young adults (typically frequent urination and urgency), ultimately followed by an increased predisposition toward urge or mixed urinary incontinence with aging. Minassian and colleagues4 report a case-control study involving 267 cases (women with urge, stress, or mixed urinary incontinence) and 107 controls. The mean age of the cases was 58 years, and the mean age of the control group was 52 years. More than half (56%) of women with adulthood urinary incontinence reported a history of LUTS as children compared to 40% of control subjects (odds ratio [OR] 2.0, 95% CI: 1.2-3.4). As expected, the highest likelihood of dysfunctional voiding occurred in women reporting urge incontinence (OR 4.4, 95% CI: 1.8-10.7), followed by mixed incontinence (OR 2.7, 95% CI: 1.5-5.2). In contrast, this predisposition did not persist in women reporting pure stress incontinence symptoms (OR 1.4, 95% CI: 0.8-2.5), suggesting that overactive bladder may persist across the lifetime in some patients, while stress urinary incontinence appears in response to secondary factors such as pregnancy and vaginal delivery.

References