In This Issue of JWOCN

This issue of the Journal includes an ostomy-themed special focus, Bladder Cancer and the Urostomy. I purposely selected this focus because it provides a follow-up to last issue's focus on quality of life in persons with an intestinal ostomy and further illustrates the growing variety and scope of ostomy-related articles in your Journal of Wound, Ostomy and Continence Nursing. Nevertheless, this issue contains far more than this special focus. It contains the latest must-read information covering wound, ostomy and continence care, not to mention the latest professional practice issues that set the context for our practice.

For more than a year, a number of Journal authors have provided expert opinion and data questioning whether all pressure ulcers are avoidable, and what criteria can be reasonably adopted by the United States Centers for Medicare & Medicaid Services (CMS) to differentiate an avoidable from an unavoidable pressure ulcer in the acute care setting. This issue of the Journal includes the ultimate must-read feature, the WOCN position statement on avoidable versus unavoidable pressure ulcers. The Society's statement is an essential component of the ongoing national conversation about hospital-acquired pressure ulcers and has implications for every acute care facility with patients who are Medicare recipients. Does the position statement agree with your opinion in this national conversation? Does it go far enough? As always, the Journal welcomes Letters to the Editor pertaining to this or any of the articles in this issue.

Nancy Walsh, Alyson Blanck, and Karen Barrett provide a valuable companion piece to the position statement in an article about their facility's response to CMS mandates about hospital-acquired pressure ulcers. Their innovative article has vital information about a successful program to accurately identify and document pressure ulcers that are present on admission and to encourage staff to apply research-based information in daily clinical practice. You will also want to read Phyllis Bonham's thorough literature review about swab cultures for diagnosing wound infection. Her review rises to the level of a must read article not only because it provides masterful and thorough research on the use of swab culture for diagnosis of wound infection and as an aid to therapeutic decision making, but also because it extends this knowledge to a research-based guideline for the performance of swab cultures in the clinical setting. Ozge Uzun, Rukiye Aylaz, and Ezgi Karadag report on the impact of an educational intervention for stage II pressure prevention. You should read this article to learn more about the effect of nurse education on stage II pressure incidence in one of the highest-risk patient groups imaginable, those managed in a critical care setting.

C. Tod Brindle and Jodie Blankenship present a series of cases illustrating principles of managing enterocutaneous fistulae in patients with abdominal surgery. Their article provides clinically relevant and immediately useful information about nursing management of the fistula and its output, as well as medical or surgical management aimed at spontaneous or surgical closure of the fistula. You will want to read their article to review essential management principles, including strategies for treatment of patients with limited economic resources.

Finally, this issue's Wound Care section introduces a new feature in the Journal, the WOC Nurse Consult. This new feature is designed to provide you with a clinical problem commonly encountered in WOC practice that requires you to use both existing knowledge and critical thinking skills to resolve. Dorothy Doughty provides our first WOC Nurse Consult, focusing on a 63-year-old patient with a nonhealing leg ulcer.

Our special focus on Bladder Cancer and the Urostomy opens with an excellent review of the epidemiology, pathophysiology, and etiology of bladder cancer by Amit Patel and Steven Campbell. Every WOC nurse will want to read this excellent review and complete the attached CE opportunity to update your knowledge of the latest trends in diagnosis and management of bladder cancer including cystectomy and urinary diversion. Jorgen Jensen, Berit Kiesbye, and Klaus Jensen report on a descriptive study of problems associated with the various forms of urinary diversion assessed by primary healthcare providers including general practice physicians and district nurses in England. You will want to read this article to gain insight into what primary care providers face when they care for the person with a urinary diversion.

The Challenges in Practice feature completes the special focus on Bladder Cancer and the Urostomy with an elegant description of a case of an older woman with an incontinent urinary diversion and recurrent leakage from her ostomy pouch. Colleen Potts and Ostomy Care section editor Barbara Hocevar provide a cogent and well-illustrated example of the critical thinking skills needed for the difficult stoma and the essential role played by WOC nurses in these "Nightmares on ET Street."

This issue's Continence Care section opens with a randomized clinical trial (RCT) evaluating the efficacy of pelvic floor muscle training in women with stress and mixed urinary incontinence, and the effect on quality of life. You will want to read this article not only because it adds to the existing evidence base demonstrating that pelvic floor muscle training is effective for stress and mixed urinary incontinence, but also to learn more about its influence on health-related quality of life. Maria Menezes, Soraya Hashimoto, and Consulting Editor Professor Vera Santos report on the prevalence of urinary incontinence in a community sample of persons living in Sao Paulo, Brazil. You will want to read this article to gain insight into the breadth of the problem of urinary incontinence in an urban Brazilian community, and to compare the prevalence reported in this study with the prevalence of urinary incontinence in your community.

The WOCNCB continues its ongoing feature with 6 questions on the topic of continent urinary diversions and orthotopic neobladders as well as ileoanal pouch anastomosis, designed both to help first-time candidates prepare for certification and to assist certified wound, ostomy, continence, and full-scope WOC nurses prepare for recertification. In addition, this issue is accompanied by the Certification Board's first-ever research review for WOC nursing practice. This review supplement is a succinct and valuable summary of some of the most important original research reports and systematic reviews published between 2007 and 2008. Look for ongoing updates from the WOCNCB in future supplements accompanying the Journal.

Evidence From Other Publications

While this component of the Context usually reviews evidence from 3 to 4 articles in each of our major fields of clinical practice, the next 3 issues will feature a single systematic review and meta-analysis from the Cochrane Library of Systematic Reviews. I have chosen to feature 3 Cochrane reviews in order to ensure you are well acquainted with this significant resource for systematic reviews, many of which answer queries pertinent to WOC nursing practice. McInnes and colleagues1 reviewed existing evidence on the use of support surfaces for pressure ulcer prevention. Their review was last updated February 2008; they searched for articles as far back as 1950. Inclusion criteria for studies were RCT, published or unpublished, that evaluated the effectiveness of beds, mattresses, mattress overlays, and seating cushions for the prevention of pressure ulcers for any patient group, in any setting. Studies that did not report the direct effect of the support surface on pressure ulcer incidence were excluded from their review. They identified 52 RCT that met their inclusion criteria; publication or abstraction dates ranged from 1960 to 2008. A standard foam hospital mattress was compared to a variety of high- and low-tech support surfaces, including sheepskin, static air-filled or water-filled supports, contoured or textured foam supports, gel- or bead-filled support surfaces, and Silicore-filled devices. You will find that some of their product descriptions differ from those commonly employed in the United States and they explicitly acknowledge that what comprises a "standard foam hospital mattress" tends to vary over time and between various countries. They also identify studies evaluating high-tech support surfaces including alternating pressure support surfaces, low air-loss beds, and air fluidized beds. These trials compared these devices to either a low-tech device or standard foam hospital mattress. Finally, the systematic review considered evidence on a variety of cushions, heel supports, and operating table overlays.

Whenever feasible, data from multiple studies were pooled and a meta-analysis was preformed. A meta-analysis combines data from multiple studies in an attempt to determine the efficacy of a given support surface for the prevention of pressure ulcers and the magnitude of that effect. The magnitude of effect may be expressed as a risk ratio. This ratio will be lower in the case of an effective support surface (indicating its association with a diminished incidence of pressure ulcers) or higher than the comparator product if it is associated with a higher incidence of pressure ulcers. Based on this detailed review, the authors conclude that low-tech alternative foam support surfaces can reduce pressure ulcer incidence when compared to a standard foam hospital mattress. However, they found less evidence that alternating and low-pressure devices prevent pressure ulcers. Nevertheless, they reported finding a single high-quality RCT comparing alternating pressure devices that concluded that alternating pressure mattresses were more effective than alternating pressure overlays. Based on the results of 3 clinical trials, the authors concluded that medical grade sheepskin was effective for prevention of pressure ulcers. Two of the trials were completed in Australia and were published in 2000 and 2004, while the third trial was published in 1964. All three used sheepskin overlays on standard hospital foam mattresses. The oldest trial found no difference between sheepskin and a standard hospital mattress. A second trial clearly favored sheepskin overlays; it was published in 2000. A third trial also favored sheepskin overlays, but a significant dropout rate (approximately 20%) combined with lack of an intention-to-treat analysis weakens the conclusions that can be drawn from these findings. The mechanism of action for a medical grade sheepskin overlay is not known, and the wound care nurse must decide whether these trials justify reevaluation of this historically interesting but seldom-used type of support surface. Pressure relieving overlays were found to reduce pressure ulcer incidence in patients undergoing surgical procedures. The evidence concerning the optimal design of the class of pressure redistribution products, as well as risk factors for pressure ulcers in the surgical patient, continues to evolve.

Unfortunately, the authors also concluded that there is insufficient evidence to determine whether the various pressure redistributing cushions or devices used to relieve pressure on the limbs are effective for reducing pressure ulcer incidence. Evidence concerning devices used to offload pressure on the heels is especially relevant to WOC and wound care nurses. The authors of this Cochrane Review identified only 3 studies; none were of sufficient quality to allow definitive conclusions. Clearly, additional research is needed to move from the current tradition- and expert opinion-based practice to an evidence-based practice model for preventing heel pressure ulcers in high-risk patients.

I strongly encourage you to review this Cochrane Review in greater detail. Reviews can be downloaded online; the URL for this review is http://www.cochrane.org/reviews/en/ab001735.html.

From the Managing Editor's Desktop

Phyllis Bonham, PhD, WOCN President Elect, will be inducted into the American Academy of Nursing.

Sandra Engberg, PhD, at the University of Pittsburgh, will be inducted into the American Academy of Nursing and has also joined the Journal as a Consulting Editor.

Mandy Fader, PhD, one of the Journal's Consulting Editors, has been appointed to the Board of Trustees of the International Continence Society.

Katherine Moore, PhD, the Journal's Continence Section Editor, has been appointed to the Board of Trustees of the International Continence Society.

Mary H. Palmer, PhD, one of our regular reviewers, has been awarded the Rodney Apell Continence Care Champion Award by the National Association for Continence (NAFC).

http://UroToday.com has scheduled the Journal's recent Evidence Based Report Card, "Nursing interventions to reduce the risk of catheter-associated urinary tract infection: Part 2: Staff education, monitoring and care techniques," by Margaret Willson, Mary Wilde, Marilyn-Lu Webb, Donna Thompson, Diana Parker, Judith Harwood, Laurie Callan, and Mikel Gray, to be abstracted on their Web site.

The goal of this feature is to recognize significant achievements by members of the JWOCN community of editors, authors, reviewers and other contributors without whom the journal would not be possible. If you have an announcement, please submit it to me at [email protected]!!

Gary Mawyer

Managing Editor

International Continence Society 39th Annual Meeting San Francisco 29th September-3rd October 2009

Reduced registration fees and free workshop for WOCN members-register now!!

WOCN is proud to announce a new collaboration with the International Continence Society (http://www.icsoffice.org) the leading, international multidisciplinary society concerned with furthering education, scientific research, clinical practice and removing the stigma of urinary and fecal incontinence.

The 39th Annual Meeting of the International Continence Society (ICS) is set to attract over 2,000 participants. Leading continence experts from across the globe will present a rich scientific programme covering breakthroughs in science, research and medicine. http://www2.kenes.com/ics/Pages/home.aspx

This year, WOCN have negotiated a fantastic deal for WOCN members. Register before the 30th of June 2009 and you will be able to attend for the reduced rate of $275 (normal rate for nurses $325) and attend a co-sponsored WOCN skin health-workshop free of charge (normally $90)!! http://www2.kenes.com/ics/registration/Pages/Registration.aspx

Free workshop to WOCN members

Skin Health and Incontinence: Evidence-Based Practice and Current Research

Faculty: Mandy Fader, Mikel Gray, Donna Bliss, Barbara Bates-Jensen

The aim of this workshop is to review and discuss the evidence-base for clinical practices designed to prevent and treat incontinence-associated skin damage. The workshop will focus on exploring the mechanisms by which skin is damaged by urine and faeces (including the effects of pressure, friction and shear); reviewing the prevalence of skin health problems in people with incontinence; discussing the reliability, validity and utility of clinical and research tools for assessing wet or damaged skin; examining the evidence to support current methods for preventing and treating skin health problems and identifying guidelines for management of skin health.

This is the first time that WOCN have collaborated with the International Continence Society-come and join us in what promises to be an exciting and rewarding conference.

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