In This Issue of JWOCN

This issue of the Journal focuses on a topic that has dominated the WOCN web forums and several recent regional meetings. The US Centers for Medicare and Medicaid Services (CMS) are moving forward with plans to adopt a pay-for-performance system for reimbursing hospitals for services rendered to Medicare patients. Typical of any significant alteration in reimbursement for this large and growing patient population, this announcement has generated a mixture of factual information, speculation, and misinformation about the proposed changes and the implications for practice. While the changes proposed by CMS will affect many areas of care, WOC nurses find themselves at the heart of these proposed changes because they refocus pressure ulcer care from one of reactive management to preventive care. Although the idea is novel to many healthcare providers, WOC nurses have long advocated prevention as the cornerstone of pressure ulcer management. This focus is evident in our daily practice, and it is clearly reflected in the Journal, which has recently published 2 special focus issues on the topic of pressure ulcer management, including one on pressure ulcer risk assessment and another on pressure ulcer prevention in acute and critical care settings. The reimbursement changes promulgated by CMS also raise fundamental questions about concepts of avoidable versus unavoidable pressure ulcers, and the criteria that define a hospital-acquired versus community-acquired pressure ulcer.

This issue of the Journal meets these evolving issues head-on with the latest update from WOCN representatives who participated in a meeting with CMS, as well as research-based and pragmatic information about the challenges of pressure ulcer prevention in the acute care setting. I believe that the timeliness of this information, along with a new feature designed to help prepare you for certification or recertification, cutting-edge research on the effect of cleansing on the skin's moisture barrier, evidence-based report cards on compression in the management of venous ulcers and probiotics for antibiotic-associated or radiation-induced diarrhea, behavioral therapies for overactive bladder, management of fecal incontinence in the acute care setting, and light therapy for a neuropathic foot ulcer truly support the title of this editorial, "Must-Read Information for WOC Nurses."

Lee Ann Krapfl and Dianne Mackey introduce the issue of evolving changes in CMS reimbursement policies in a guest commentary. Their comments reflect ongoing efforts by the WOCN, working in close collaboration with the NPUAP, to articulate comments and concerns about proposed changes. Read their commentary to obtain accurate and up-to-date information about pressure ulcer prevention and evolving reimbursement policies.

After reading the guest commentary, you will want to turn your attention to the article by Cynthia Padula, Evelyn Osborne, and Joyce Williams describing a quality improvement project designed to promote prevention and early detection of pressure ulcers in hospitalized patients. Read their article to get ideas about updating and strengthening your facility's pressure ulcer prevention program, and to gain insights into the challenges associated with influencing daily practice and translating these changes into meaningful reductions in the incidence of hospital-acquired pressure ulcers. This article is followed by commentary from Dorothy Doughty. Her commentary also provides essential reading for any WOC nurse interested in concepts and controversies surrounding avoidable versus unavoidable pressure ulcers in light of changes in CMS reimbursement policies.

After digesting the information in these articles and commentaries, you will want to turn your attention to Mary Louise McElhinny and Christine Hooper who report on a quality improvement project focusing on prevention of hospital-acquired heel pressure ulcers. A careful review of their article will provide an excellent example of the considerable challenges associated with the prevention of heel pressure ulcers in very high risk populations, and a lucid and honest analysis of the reasons their program did not lead to the anticipated reduction in ulcer incidence.

David Voegeli reports on a randomized trial comparing the effects of 6 different methods of washing on the skin's moisture barrier. His study is especially valuable because it describes the effects of washing with soap and water, the effect of using a hospital standard washcloth, and the effect of patting the skin dry versus drying using a towel to rub moisture from the epidermis. Multiple physiologically meaningful outcomes are used to evaluate changes in the skin's moisture including pH, transepidermal water low (TEWL), and hydration. This research report extends the Journal's ongoing and pioneering focus on moisture-associated skin damage, and it provides must-read information about a common but remarkably understudied aspect of daily nursing care, bathing. It is especially important for the WOC nurses seeking to present pressure ulcers not only through pressure offloading, but also by maximizing skin tolerance and preventing incontinence-associated dermatitis or intertrigo in skin folds.

Jill Milne reviews behavioral therapies for patients with overactive bladder (OAB). While behavioral treatments have long been considered a mainstay treatment for urinary incontinence, considerably less research has been completed evaluating the efficacy of these interventions in the management of overactive bladder, especially in those patients with overactive bladder without associated urge incontinence (OAB dry). Read this article for a comprehensive and cogent overview of the effectiveness of lifestyle modifications, pelvic floor muscle training, and bladder training in patients with overactive bladder dysfunction.

Judith Wishin, T. James Gallagher, and Eileen McCann discuss emerging options for managing fecal incontinence in the hospitalized patient. Read their article for a cutting-edge review of the sparse but growing body of evidence on options for managing fecal incontinence in the acute care setting, including the use of fecal or bowel management systems. This discussion is especially timely since it provides evidence-based recommendations for managing a common and powerful risk factor for pressure ulcer development, fecal incontinence.

Retta Sutterfield describes a novel intervention, laser light therapy, for managing a neuropathic plantar ulcer in a patient with a Charcot foot. This case study is an outstanding example of one of the primary purposes of our Clinical Challenges section, to provide authors an opportunity to describe their experiences with novel interventions not supported by extensive clinical experience or research. After reviewing this interesting case study, you will want to read Renee Cordrey's commentary that deftly identifies available research on the use of laser light therapy for wound healing while identifying gaps in this evidence base and implications for practice.

This issue is rounded out by 2 must-read Evidence-Based Report Cards. In the first report card Dr Laura Bolton reviews evidence on the use of compression for venous insufficiency. In the second, Carolyn Eddins and I follow up last month's probiotics Evidence-Based Report Card by evaluating the role of probiotics in the management of antibiotic-associated and radiation-induced diarrhea.

In addition, please don't overlook Dorothy Doughty's stellar View From Here: History of Ostomy Surgery feature. Ostomy surgery has a long history and her review reminds us of the origins and development of ostomies on the road to specialty practice.

A New Must-Read Feature: Preparing for Certification

Time and experience have taught us to retain only those features that add some tangible benefit to the Journal's readers, and WOCN Society members in particular. It has been a number of years since we have added a new element, but we believe you will find the addition of our newest feature, "Preparing for Certification," interesting, educational, and valuable. In this first edition, Jane Fellows provides 3 exemplar questions in the area of wound care identical to the type of questions encountered on WOCNCB certification examinations. She not only provides you with the correct answers, she also provides you with a rationale as to why other distractors are incorrect. Read and answer the questions first, then compare your responses to confirm the correct answer and determine why those attractive distractors are not the best response. You may want to keep these features; they provide information that will be valuable whether you are preparing for certification for the first time, preparing to add a new or expanded certification to your credentials, or recertifying.

Evidence from Other Publications

WOUND CARE

The question of how many pressure ulcers are avoidable when patients receive adequate preventive care remains controversial. Some researchers and clinicians believe this number is very small indeed, while others believe a significant portion of hospital-acquired pressure ulcers are truly unavoidable. De Laat and associates1 compared pressure ulcer prevalence before, 4 months following, and 11 months following implementation of an evidence-based pressure ulcer prevention protocol combined with introduction of viscoelastic foam mattresses in a 900-bed, university-based hospital in the Netherlands. They found that inadequate implementation of prevention measures diminished from 19% to 4% (P > .001) and pressure ulcer prevalence declined from 18% to 11% 11 months after implementation of prevention protocols. However, when the introduction of the pressure redistribution surface was controlled for, changes in the behavior of nurses in pressure prevention (the frequency of patient repositioning) did not change significantly, with adherence to turning schedules remaining level at 10% before and following an educational intervention. How does the WOC nurse improve and maintain adherence to repositioning schedules, an essential component of any pressure ulcer prevention program? Read this issue for additional insights into this ongoing and (as yet) unresolved concern.

OSTOMY CARE

Laparoscopic and robot-assisted laparoscopic surgical techniques are increasingly popular choices among patients and surgeons, but prospective randomized clinical trials comparing clinically relevant outcomes to open surgical procedures remain scarce. Polle and coinvestigators2 completed a randomized clinical trial comparing restorative proctocolectomy (ileoanal pouch anastomosis) completed using a hand-assisted laparoscopic or open surgical technique. Specific outcomes of the trial were health-related quality of life (QOL), functional outcomes (defecation frequency, incontinence, and sexual dysfunction), morbidity, body image, and cosmesis. At a median of 2.7 years following surgery, no statistically significant differences were found in QOL, functional outcomes, or morbidity. However, body image and cosmesis scores were significantly higher among women who underwent laparoscopic as compared to open surgery. In addition, women who underwent open surgery scored lower than male patients, regardless of approach. This study is among the first to evaluate the effect of surgical approach on long-term outcomes among patients managed by a proctocolectomy. These findings provide reasonable evidence that female patients, in particular, may gain long-term psychosocial benefits from laparoscopic surgery in terms of both body image and cosmesis when undergoing restorative proctocolectomy.

CONTINENCE CARE

Difficulty initiating micturition is a common complaint in older men that is traditionally linked to prostatic enlargement, often with little supporting clinical evidence. In contrast, traditional wisdom dictates that women rarely experience bladder outlet obstruction or difficult voiding because of their comparatively short urethral course. Rather, it is assumed that women are more likely to experience urinary incontinence and that residual volumes are caused by poor detrusor contraction strength. Haylen and associates3 evaluated lower urinary tract symptoms in 592 women referred to an urogynecology clinic and found that 39% complained of difficulty initiating their urinary stream. Two factors, vaginal wall prolapse and advanced age, were most commonly associated with an increased likelihood of difficulty initiating urination. Other associated factors were prior surgery for stress urinary incontinence and hysterectomy. The results of this descriptive study provide an important lesson for any clinician interested in continence management: the so-called "obstructive symptoms" commonly described in men and typically attributed to prostatic enlargement are surprisingly common in aging women. However, the study also raises an equally important question that has not yet been answered: why does increasingly severe vaginal wall prolapse make it difficult for women to initiate urination? It is often presumed that kinking of the urethra leads to functional obstruction of the bladder outlet and difficulty starting the urinary stream. However, more than 20 years of urodynamic testing also leads to the inescapable conclusion that these women are more likely to experience difficulty initiating or maintaining a detrusor contraction sufficient for bladder emptying as they are to experience clinically relevant bladder outlet obstruction. While additional research is clearly needed to answer this clinically important question, the results of this study serve as a reminder that traditional models attributing so-called "obstructive" lower urinary tract symptoms in men, including difficulty initiating a urinary stream, to prostate enlargement must be abandoned for a more comprehensive and more nuanced understanding of the possible causes of these bothersome symptoms.

References