In This Issue ofJWOCN
Although this issue of the Journal does not have a content-based special focus as many of our issues do, multiple articles do address the issue of "Here is the evidence, but what does it mean to my practice?" This question sounds straightforward at first glance, but the answer remains surprisingly elusive. For example, facilities are likely to state that routine repositioning is a standard part of pressure ulcer care, but observation of what happens in daily practice often differs significantly from this assertion. Similarly, compression is considered a central component of the management of venous leg ulcers, but the abstracts I read at the WOCN National Conference and the World Union of Wound Healing Societies spoke to large gaps between research and practice. At first glance, this disparity can be explained by a simple statement, "The evidence supports the practice, but clinical practice has not caught up." However, closer inspection reveals gaps in the evidence that challenge both our ability to readily apply research findings in the clinical setting, or even the efficacy of some of the interventions or assessments we hold most dear. Another explanation may be summarized in the statement, "The research findings are so esoteric and hard to understand, I am not even sure where to begin." While this does indeed seem to apply to some published studies, it ignores the vast majority of clinically based research reports that provide valuable and insightful answers to pressing issues, such as "How do I prevent hospital-acquired pressure ulcers?", "How do I ensure that my patient with a new ostomy can change her pouch without assistance?", or "How do I complete a continence consult in a hospital?" The Journal and its authors are exquisitely aware of these matters, and we continue to strive to provide pragmatic links between research and practice. This provides one more reason why the articles in this issue can truly be described as "must read."
In this issue's Wound Care section, Karen Lyon evaluates the outcomes of 4 management strategies (standard wound care, growth factor therapy, standard care plus hyperbaric oxygen, and growth factor plus hyperbaric oxygen therapy) used in the management of lower-extremity ulcers in persons with diabetes mellitus. Does it seem apparent that combining therapies will make all the difference, or are you convinced that in reality the standard treatment is just as good as any of the more novel interventions? Read this study to find out the results. They may surprise you and I guarantee they will challenge you to reconsider your experiences with the various treatment options for these challenging wounds. In the July/August issue of the Journal, Hocevar and coworkers1 reported on their initial experiences with a fistula and wound management system. In this issue, Rasmus Skovgaard and Hans Keiding estimated wear time and supply costs to provide an economic analysis of their pouching system as compared to standard management. Read this article to gain insight into another essential component of any analysis of a new product or technology-its cost.
In this issue's Ostomy Care section, Ginger Salvadalena systematically reviews the literature to determine the incidence of complications among persons living with colostomies, ileostomies, and urostomies. Do not be discouraged by her well-reasoned criticisms; they are meant to challenge and inform rather than condemn. You will want to read this systematic review to evaluate the existing evidence about the frequency of complications following ostomy surgery, and about the type of additional studies needed to move our measurements forward.
In this issue's Continence Care section, Suzanne Hagen, Lesley Sinclair, Kate Niven, Katherine Moore, and Brian Buckley report on the results of the URGENT group's meeting to discuss priorities for continence care and urogenital health research. WOC and continence nurses will want to review and consider the research priorities identified by this group. Everyone will want to read this article to consider the points about the issue of gaps between available evidence and clinical practice, and how the questions asked by researchers and the study methods used to answer these questions impact this persistent question.
Wendy Bower reports on the self-reported effects of incontinence on quality of life. While this question has been addressed in multiple studies of adults and women in particular, considerably less research has focused on children. You will want to read her article to increase your understanding of how urinary incontinence influences the quality of life in children, and to determine whether the instrument she uses to measure this important dimension of health is "ready for clinical use" or is in need of further investigation before being incorporated into your management of these challenging children.
This issue incorporates 2 Evidence-Based Report Cards (EBRCs). The first, authored by Lee Ann Krapfl and colleague, focuses on repositioning for pressure ulcer prevention. The second, authored by Janet Ramundo and associate, evaluates the efficacy of ultrasonic mist therapy. The EBRCs are purposely designed to enable you to quickly and efficiently evaluate the evidence associated with a clinical question with relevance to WOC nursing practice, and to determine its impact on your practice. Should we assume that repositioning every 2 hours is an essential component of an evidence-based pressure ulcer prevention program? Is it apparent that the 30[masculine ordinal indicator] semi-Fowler's position is superior to other options? Are you certain that your facility's patients remain in place after they are repositioned until it is time for the next turn? Read Krapfl's EBRC for the surprising and insightful answers to these questions, as well as essential information about the clinical implications of existing evidence in a rapidly evolving regulatory environment. Ramundo's EBRC is one of an ongoing series that focuses on debridement techniques and their effect on wound healing. The evidence in this article about the effect of ultrasonic mist on debridement and wound-healing outcomes may surprise you and certainly will prompt you to consult with clinical colleagues and industry partners to understand more about this novel instrument in our therapeutic armamentarium.
The Challenges in Practice article is valuable to your practice because it deals with that large group of disorders and scenarios we must deal with on a daily basis even though clinical evidence is limited or almost absent. In this issue's Challenges feature, Sue Arford discusses the management of a young adult with frostbite of the feet. Read her article for pragmatic advice on managing this significant cold injury, as well as more recent evidence concerning minimizing delayed adverse effects due to prolonged tissue exposure to thromboxane and prostaglandins.
Janice Beitz provides this issue's Research Spotlight, focusing on data analysis and selection of the best statistical test. Both researchers and consumers of research (that includes everyone) should read this article for a clear and understandable explanation of an often-intimidating aspect of the research process. Finally, in this issue's Getting Ready for Certification, Jane Fellows reviews some basic principles of question construction, the 3 levels of questions that appear in the various WOCNCB examinations, using 3 questions about lower extremity ulcers as examples. Also, you will want to read Donna Loehner's commentary about recertification using Professional Growth Points.
Evidence From Other Publications
Wound Care
When discussing pressure ulcer prevention, I often hear something like the following statement: "Hospital-acquired pressure ulcers are a direct reflection of nursing quality; therefore, increasing nursing to patient staff ratios will reduce the incidence of these preventable wounds." Despite a growing body of evidence to contradict this belief, I continue to find that this opinion tends to be accepted by healthcare regulators, physicians, and nurses. I was both surprised and pleased to read the insights of Padula and associates2 when they stated, "While nursing care is clearly essential to prevention and management of PU, the results of this quality improvement project suggest that impacting nursing sensitive indicators may not be enough[horizontal ellipsis]. Rather, the medical team must be actively involved[horizontal ellipsis]."(p73) Indeed, I would argue that the entire healthcare team must be involved-emergency medical services personnel who place patients on stretchers with abysmal pressure-distribution characteristics in the field and then transport them to the emergency department, opearting room staff who must act for even the most robust and healthy patients who are suddenly rendered entirely immobile while under the influence of anesthesia, and the emergency department staff who are increasingly obliged to care for at-risk patients for 12 hours or longer because inpatient beds are occupied. Bolton and associates3 analyzed the effects of mandated nurse-patient ratios in California acute care facilities, including hospital-acquired pressure ulcers. While the general trend in data over a 4-year period (from 2002 to 2006) indicated a 14% reduction in hospital-acquired pressure ulcer incidence, this difference was not statistically significant. The authors offer a variety of interesting explanations for the failure to significantly link changes in nurse-patient ratios to various "nurse-sensitive" outcomes, but I agree with Padula, Osborne, and Williams when they observe that pressure ulcer prevention is a transdisciplinary issue, and its solution will require coordinated, transdisciplinary communication and intervention to resolve.
Ostomy Care
Abdominal fistula management is always a serious challenge for both patient and WOC nurse, especially when it is associated with a significant abdominal wall defect. Visschers and coworkers4 reviewed their experience with a remarkably large group of patients treated for enterocutaneous fistula over a 15-year period. Despite the enormity of the challenge posed by these fistulae, they reported that closure was ultimately achieved in 87.4%, and that reconstructive surgery was ultimately successful in 90.7%. Nevertheless, a significant portion of these patients (9.6%) died, and the median time between fistula occurrence and restorative surgery was 53 days and was as long as 207 days in at least 1 case. Two factors, presence of an abdominal wall defect and serum albumin levels, were found to be the strongest predictors of successful closure. WOC nurses have a long-standing tradition of advocating for aggressive nutritional management of patients with chronic wounds, and these data provide additional evidence that nutritional support is not merely an adjunct to a skilled surgical closure. Rather, it is a key to its long-term success.
Continence Care
While it is generally accepted that aseptic technique is mandatory when inserting an indwelling catheter in the acute care setting, less is known about the risk of catheter-associated urinary tract infection in the home-care setting. Cheung and coinvestigators5 reported on a randomized clinical trial comparing meatal cleansing using sterile water versus 0.05% chlorhexidine to prepare the urethral meatus. Their subjects were comparable to home-care patients seen in the United States. They tended to be elderly (mean age of groups was 74.8-80.8 years in the 2 groups), with multiple comorbid medical conditions, and have used an indwelling catheter for longer than 1 year. Unlike common practice in North America, the nurses donned sterile gloves, a surgical mask, and apron for insertion, reflecting true aseptic technique. Analysis of the groups revealed no significant difference in bacteriuria between the groups, and no symptomatic urinary tract infections occurred in either group during the data collection period of 2 weeks. The results of this study, although more suggestive than conclusive, remind us that the aseptic technique preferred when inserting a short-term indwelling catheter in a hospitalized patient should not determine the optimal technique for catheterization in the home-care setting.
References