In This Issue of JWOCN

Pressure Ulcer Prevention

This issue of the Journal includes a special focus on pressure ulcers that represents the growing presence of international authors contributing to the Journal. Dr Lena Gunningberg studied the effect of quality improvement programs for pressure ulcer prevention between 2002 and 2004. Preventive interventions were introduced on the basis of clinical practice guidelines and methods promulgated by the European Pressure Ulcer Advisory Panel (EPUAP). Not surprisingly, in the 2 years following the introduction of clinical guidelines, pressure ulcer prevalence declined on each of the units by as much as 9.5% and the use of preventive measures such as pressure reducing support surfaces rose significantly. Similarly, Chaves, Grypdonck, and Defloor evaluated pressure ulcer prevention in the homecare setting. They surveyed 41 homecare agencies in the Netherlands using a questionnaire, open-ended questions, and a checklist that allowed wound care experts to document conformity and quality of preventive protocols with national clinical practice guidelines. Although the vast majority of agencies (78%) had a prevention guideline in place, only 13% had executed revisions since the last Dutch clinical practice guideline was introduced. The findings from both of these studies are important because they illustrate the ongoing challenges inherent in translating evidence-based guidelines into clinical practice. Chaves, Grypdonck, and Defloor found evidence of documentary compliance with pressure ulcer prevention guidelines, but more significant gaps were identified when they evaluated whether these documents were reexamined and revised as national practice guidelines for pressure ulcer prevention evolved. As a result, while policies were in place in nearly 80% of all homecare agencies responding to their survey, the mean quality score was 47 +/- 18 out of a possible 100 points. As Gunningberg demonstrated, the application of EPUAP guidelines could produce significant reductions in pressure prevalence in a single acute care facility. She attributed much of their success to the routine surveying of pressure ulcer prevalence. Although this task is clearly laborious, it does focus attention on the problem of pressure ulcers and provides regular checkpoints for clinicians to measure the success of preventive interventions.

Nakagami, Sanada, Konya, Kitagawa, Takada, and Tabata (a group of nurse researchers from the University of Tokyo that includes 2 doctoral prepared WOC nurses) evaluated the efficacy of 2 dressings in the prevention of pressure ulceration of the heel. Specifically, they compared shear and tissue interface pressure forces exerted over the heel following an application of a thin-film dressing and a dressing especially designed to reduce these forces. Although tissue interface pressures did not differ between the dressings, the shear forces produced by the new dressing were statistically less than that measured when a thin-film dressing was applied. On the basis of these findings, the authors concluded that the dressing can reduce shear forces but not tissue interface pressures that may lead to pressure wounding in the immobile patient. Although the results of this well designed and careful study do not reveal the ideal device needed to prevent pressure ulcers on the heel, the study is an important interim step in the search for the best device.

Pressure Ulcer Pain

Dr Deborah Rastinehad, a doctoral prepared wound/ostomy nurse from the University of Minnesota, used a qualitative methodology to explore and interpret pressure ulcer pain. She found that the pain is an inevitable aspect of the pressure ulcer experience and that these experiences are not limited to specific stages as previously believed, consistent with the previous studies.1 The experiences related by the patients she surveyed also revealed their perceptions of the failure of care providers and modern technology to relieve or prevent pain, and the stress, tension, and anxiety provoked by this failure. Her findings are significant because they remind us of the ever-present but frequently under-diagnosed specter of pain in pressure ulcer management, and of the disparity between our perceptions and patient's perceptions of these experiences; their frequency, causes, and intensity.

Analysis of Urine From an Incontinence Pad

Susan Midthun and A. Wayne Bruce studied whether the true-negative results of a urine dipstick pressed into an incontinence pad were adversely affected by a 2-hour delay in analysis. They collected spontaneously voided urine specimens, cultured part of the specimen, and poured a part of it into an incontinence pad. After a 2-hour delay, a dipstick was pressed into the incontinence pad to determine whether the urine that was negative upon initial culture would remain negative when tested by dipstick analysis after sitting in an incontinence pad. Even after a 2-hour delay, only 0.5% of the sample changed from negative to positive. The results of this highly pragmatic experiment are particularly important for continence clinicians who must judge the veracity of urinalysis results obtained from an incontinence pad before making decisions about treatment. Their applicability is even more apparent when considering the recently promulgated F315 tag that now applies to all long-term care facilities receiving Medicare funding.

F315 and WOC Nursing

In this issue's Clinical Challenges, Jennifer Hurlow, a geriatric nurse practitioner and a WOC nurse, describes the opportunities for WOC nurses afforded by the newly revised Centers for Medicare & Medicaid Services (CMS) tag F315. I urge you to read her description carefully and to note how she relates F315 to the recently revised F314 tag and the demand for preventing incontinence associated dermatitis. WOC nurses are uniquely positioned to meet the needs of these patients, and the newly revised tags provide both economic and clinical opportunities favoring the full-scope practice that forms the cornerstone of our society and clinical practice.

Discharge Information Needs of Patients After Surgery

Pieper, Sieggreen, Freeland, Kulwicki, Frattaroli, Sidor, Pallechi, and colleagues reviewed the current literature on patients' discharge needs after surgery in this issue's continuing education article. Their group identified a variety of informational needs that are essential to a successful transition to home or homecare, emphasizing the role of the WOC and advanced practice nurses in developing educational programs for patients and their care providers. Given ever-diminishing hospital admission times, and the rise of minimally invasive surgical procedures, the demand for teaching patients and care providers to self-manage is likely to increase more and more. This article provides a comprehensive overview of the existing knowledge in this area and suggests strategies for WOC nurses to develop and implement effective educational programs.

Evidence From Other Publications

Wound Care

In the October 2005 issue of the Journal of the American Geriatrics Society, Bergstrom and colleagues2 examined the outcomes of pressure ulcer treatment in 882 patients residing in 95 long-term care facilities. Participants were enrolled regardless of whether they were admitted with a pressure ulcer or developed one while in residence. After 12 weeks of treatment, stage II-IV ulcers cleansed with soap and water showed less reduction in pressure ulcer area than those managed by antiseptic, antibiotic, or commercial cleansers. Similarly, pressure ulcers managed by moist dressings (defined as hydrocolloids, thin film, island composite, or similar dressings) were reduced in area when compared to dry-covers (defined as gauze, nonadherent, compression, or dry-absorptive) dressings. Although widely accepted by WOC nurses and other clinicians, some controversy continues to surround the idea that moist-wound healing is superior to older methods, and even greater uncertainty exists concerning the advantages of cleansers versus "good old soap and water." We are reminded of these persistent doubts every time a colleague posts a case where a clinician "demands" their patient be managed by a dry-cover dressing or a purchasing agent informs nurses that cleansers are "too expensive" compared to soap and water. Those who favor these traditional methods of pressure ulcer management may criticize the evidence provided in this article because of its retrospective methodology. However, I would argue that data such as these are vitally important because they provide insights that complement what is learned from prospective clinical trials. Specifically, the retrospective trials (i) reflect "real world" practice in a way that randomized clinical trials do not, (ii) incorporate a broader variety of patients than tightly controlled prospective trials, and (iii) avoid the sometimes significant bias introduced when researchers provide the extra attention and rigid application of an intervention needed to conduct a prospective randomized clinical trial. Therefore, I would argue that the evidence provided by Bergstrom's group is important because it demonstrates the efficacy of applying principles of moist-wound healing and commercial cleansing products in a real-world setting with all the accompanying chaos and variability that characterize wound care in the long-term care setting.

Ostomy Care

Harris and coworkers3 reviewed a database of 345 ostomies created in 320 patients for a period of 8 years and reported on associated complications and mortality. Complications occurred in 25% of the patients; their incidence and type are comparable to other studies, including Ratliff's group,4 which reported on peristomal complications in 220 patients. Similar to other studies, they also reported that diversion type (loop versus end colostomy versus ileostomy) affects the complication rate, as does surgical technique. Surprisingly, they also reported that increasing age did not predict the likelihood of complications. However, the context of ostomy creation (elective versus emergency) profoundly influenced the likelihood of complications. Specifically, patients undergoing emergency surgery were more likely to experience multiple postoperative complications, including death within 1 year following ostomy creation. When mortality trends were followed for 2 years, however, the likelihood of death for those undergoing emergency surgery was no greater than those undergoing elective surgery. The overall mortality rate in this study was significant, at 47% within 8 years of surgery. Although multiple factors clearly contribute to this outcome, such as coexisting diseases, the underlying diagnosis leading to ostomy surgery, and age, the contribution of ostomy surgery must not be minimized. This important observation is reflected in a study by Zorcolo and associates,5 who found that the death rate among patients with left colonic emergencies associated with cancer or diverticular disease was three times greater than in patients with similar causes treated by primary colonic reanastomosis. In addition to expanding our knowledge of complications associated with stoma creation, the findings of this study reemphasize the increased mortality risk associated with emergency ostomy surgery and the need for ongoing management by a WOC nurse.

Continence Care

Despite significant strides in treatment, our understanding of overactive bladder (OAB) remains rudimentary. In the March 2006 issue of the Journal of Urology, Fitzgerald and colleagues6 studied a population-based cohort of 2109 women aged 40 to 69 years. Using a questionnaire that relied on recall of childhood voiding patterns, they found that women who reported childhood lower urinary tract symptoms such as urgency, daytime voiding frequency, nocturia, and urge incontinence were more likely to report symptoms of OAB as adults than were women who did not recall voiding problems during childhood. Previous studies, also based on self-reported lower urinary tract symptoms, have linked childhood voiding disorders with OAB7-9 and detrusor overactivity.10 Although these studies do not provide definitive proof of a genetic basis for OAB or its natural history, they do form the basis of a growing body of evidence suggesting that OAB may have a genetic basis. Further population-based studies are needed to define the natural history of OAB and determine whether it persists throughout the affected person's lifetime as these studies suggest. Additional research is also needed to define whether OAB has a genetic base and where the specific defects predisposing to its presence are located.

References