In This Issue of JWOCN

We do not regularly publish a separate Professional Practice section, primarily because most features that qualify as professional practice content fit into one of our clinical sections. However, this issue contains an article that applies to every WOC nurse and deserves to be shared with clinical and business leaders at your facility. Preparing for a disaster is a familiar concept for almost every WOC clinician, but we have been amazingly fortunate that so few of us have been forced to confront the underlying reality. Bernie Cullen, in a substantive follow-up to her View From Here entitled "Katrina Survivor",1 discusses the realities of disaster planning based on the first-hand experience. You will find some of the information she provides chilling, and some of it sobering, but I guarantee that you will benefit from reading this important article.

In our Spotlight on Research, Sandie Engberg talks about systematic reviews and meta-analyses. These techniques lie at the heart of the ongoing effort to ensure that practice is evidence-based. As Engberg points out, it is necessary to study studies themselves, if we are to make sense of the professional literature and separate valuable research from optimistic theorizing or subtle marketing. This issue's Evidence-Based Report Card follows up on this theme by summarizing the existing evidence related to enzymatic debridement. Read this regular feature of the Journal to get a succinct summary of evidence related to collagenase and papain-urea for the debridement of necrotic tissue in chronic wounds.

A View From Here feature article opens this issue's Wound Care section. Matthew King tells the story of the development of Dakin's solution in the early 20th century. Dakin's solution remains in use, but King's narrative reminds us of its enormous historical significance as clinicians attempted to manage the horrendous wounds associated with mechanized warfare during a period before the discovery and synthesis of antimicrobial drugs. Next, Ayise Karadag continues our timely series of publications focusing on pressure ulcer prevention in the acute care setting. Read her article to gain knowledge of what preventive measures are routinely practiced by nurses in critical units and what interventions are not regularly practiced.

Barbara Pieper, Thomas Templin, Thomas Birk, and Robert Kirsner report on the effects of chronic venous disease on walking mobility in patients with a history of injection drug use. Pieper and colleagues have a track record of reporting research in this special population,2,3 and this article is especially appropriate because it links concepts of chronic venous disease to walking speed and mobility. This knowledge not only applies to the incredibly challenging population served by Dr Pieper and her colleagues, it also provides knowledge about a valid instrument that can be used to determine the impact of chronic venous disease on mobility in other populations with venous leg ulcers.

This issue's Ostomy Care section also opens with a View From Here by Mike D'Orazio and Christine Ozorio, who discuss the ongoing challenge of meeting the long-term rehabilitation needs of persons living with ostomies. The issues raised in this critique may be succinctly summarized by their question, "what will happen going forward should I need assistance beyond my own abilities?" While wound management continues to be a rapidly evolving field, and continence management continues to attract an elite group of advanced practice nurses in particular, ostomy care remains the heart of WOC nursing practice. Nevertheless, the delivery of long-term rehabilitation services is particularly challenging given the growing demands and associated financial incentives relative to continence and wound care.

Thom Nichols and Michael Riemer also explore the challenges associated with long-term rehabilitation after creation of an ostomy in their article about the impact of stabilizing forces on postoperative recovery. Read this article to gain new knowledge about the influence of stability on your patient's relationship with a spouse or partner and the effect of job stability on life satisfaction when faced with the considerable challenges and stresses associated with stoma surgery.

The Continence Care section opens with a CE article reviewing urologic management of neurogenic bladder care in persons living with a spinal cord injury. Nancy Fonte summarizes the pathophysiology, assessment, and treatment options for maximizing continence while preserving long-term renal function in this special population. Perhaps more than any other population, managing persons with spinal cord injuries remind us that we are all continence nurses, we are all ostomy nurses, and we are all wound nurses. How can I adequately manage my patient's urinary incontinence while ignoring his apparent perineal skin damage, or manage his bowel program without considering fecal diversion should conservative management fail to prevent fecal incontinence or associated skin damage?

Kathleen Hunter, Katherine Moore, and Marion Allen report on a feasibility study examining lower urinary tract symptoms (LUTS) in persons undergoing hip arthroplasty. As Karadag notes in her article about pressure ulcer prevention, bowel, bladder, and skin care are often perceived as low-priority needs in patients with orthopedic or cardiovascular disorders. Unfortunately, clinical experience clearly tells us that bothersome LUTS frequently occur in patients who undergo hip arthroplasty. Read this article to increase your knowledge of the challenges associated with designing and completing a study of LUTS in this population, especially as patients complete more and more of their postoperative courses in the home, long-term care, or long-term acute care settings.

This issue's Challenges in Practice focuses on an injury that is frequently seen by some WOC nurses and quite uncommon for others. Myra Varnado describes an unusual case of frostbite in her practice, which is based in Independence, Louisiana. Read this article and Denise Nix's excellent commentary, to refresh your knowledge, or to learn more about the evaluation and management of the patient who experiences the tissue damage and pain associated with frostbite.

Evidence From Other Publications

WOUND CARE

While WOC nurses require little persuasion that "wet-to-moist" wound care is far less than optimal for the vast majority of chronic wounds commonly encountered in our practice, this technique continues to enjoy considerable popularity among others. In a recent issue of the International Wound Journal, Lavery and coinvestigators4 reviewed the Medicare claim records of 1135 patients with diabetic foot ulcers managed by negative pressure wound therapy (NPWT) in a home care setting versus claims from patients whose ulcers were managed by wet-to-moist therapy. Significantly more patients managed by NPWT achieved wound closure at 12 and 20 weeks than did patients managed by wet-to-moist therapy. This benefit was found for all wound sizes. Even more encouraging, cost analysis revealed that NPWT was no more costly than wet-to-moist therapy at the 20-week point.

OSTOMY CARE

Crohn's disease remains a common cause of temporary and permanent fecal diversion. Galandiuk and colleagues5 used a multivariate analysis to identify factors predicting an increased risk for permanent intestinal ostomy among a group of 356 patients with Crohn's disease. Eighty-six patients required surgical management of their inflammatory bowel disease, and 49% ultimately required the creation of a permanent ostomy. Two factors, anal-canal stricture and colonic Crohn's disease, were associated with a significantly increased risk of permanent intestinal diversion. The presence of colonic Crohn's disease alone increased the risk of permanent intestinal diversion more than 5-fold (P = .0045, odds ratio [OR] = 5.4). The presence of an anal canal stricture alone raised the risk 3-fold (P = .0165, OR = 3.0). When both factors were present, persons with Crohn's disease had a more than 30-fold increased likelihood of permanent intestinal ostomy creation (P = .0023, OR = 33). Despite advances in surgical options and pharmacotherapy for Crohn's disease, permanent intestinal diversion remains a mainstay of treatment in many cases. Knowledge of the risk factors benefits both clinicians and patients faced with the need to surgically manage this devastating disorder.

CONTINENCE CARE

When managing patients in a long-term care, rehabilitation, or the home-care setting, WOC nurses typically encounter little controversy when advising care providers to consider asymptomatic bacteriuria an inevitable consequence of long-term indwelling catheterization and to avoid its treatment. However, treatment of asymptomatic bacteriuria in an effort to prevent urosepsis remains common in the critical care setting. In a recent issue of Critical Care Medicine, Leone and coworkers6 reported on a randomized clinical trial of 60 patients. One group was randomized to a catheter change and short course (3 days) of antibiotic treatment in response to culture-proven, but asymptomatic bacteriuria diagnosed within 48 hours of catheter insertion, while the other group received no catheter change and no antimicrobial treatment. Three patients in each group developed urosepsis (P = NS), and the likelihood of a positive urine culture at days 7 and 15 was not affected by catheter change and antimicrobial treatment (P = .1). Although these results are hardly surprising to the clinically experienced WOC nurse, they are especially helpful when interacting with critical care physicians who are likely to argue that this care setting constitutes a "special case" that overrides the evidence about the futility of treating asymptomatic bacteriuria in the patient with an indwelling urinary catheter. Furthermore, I predict that the need to offer persuasive evidence will be particularly timely given the recent ruling from the Centers for Medicare & Medicaid Services concerning reimbursement for hospital-acquired, catheter-associated UTI.

References