In This Issue of JWOCN

This issue reflects the ongoing focus on pressure ulcer prevention as acute and long-term care facilities respond to changes in both regulations regarding facility-acquired pressure ulcers, as well as changing expectations among patients, families, and clinicians themselves. The special focus for this issue, Heel Pressure Ulcers (HPU), also rises from this ongoing evolution in patient management. Amy Clegg, Daria Kring, Judy Plemmons, and Leanne Richbourg report a timely and important study of characteristics of HPU in acute, long-term, and home care settings in North Carolina and Virginia. This article qualifies as must-read information because it reveals important information about comorbid conditions associated with HPU and some conditions that did not emerge as closely associated. Vicky Lyman reports on a quality improvement project designed to reduce the incidence of pressure ulcers and HPU in particular. Set in a large nursing home, Lyman describes a protocol that combined risk assessment using a validated instrument and use of a heel protection device, resulting in a significant reduction in HPU. You will want to read her article in order to better understand how her facility was able to reduce its HPU rate by 95%, and how you might apply this experience to the pressure ulcer prevention program at your facility. This issue's Evidence-Based Report Card completes the special focus articles. Joan Junkin and I report results of a systematic review of the effectiveness of pressure redistribution surfaces and heel protection devices for the prevention of HPU. You will want to read this article to identify the surprising paucity of evidence concerning these devices and to gain additional insight into criteria you may wish to consider when selecting the best support surface and heel protection device when supporting clinical evidence is lacking.

In addition to these articles, this edition of the Journal offers even more cutting-edge knowledge about pressure ulcer risk assessment. Morris Magnan and JoAnn Maklebust explore the relationship between pressure ulcer risk assessment and prevention interventions in a follow-up to their research project evaluating a computer-based program for teaching novice and experienced nurses to use the Braden Scale. You will want to read this article not only because it explores the relationship between which preventive interventions are associated with Braden subscale scores but also because it provides insights into how combinations of subscale scores influence nurses' decision making. Letitia Faria Serpa, Vera Lucia Coonceicao de Gouveia Santos, Gustavo Gomboski, and Sandra Marina Rosado report a study of the predictive validity of the Waterlow Scale for assessing pressure ulcer risk. You will want to read this article because of its focus on an instrument for measuring pressure ulcer risk that is less well known to many North American readers and to evaluate your impressions of its performance when compared to the Braden Scale for Pressure Sore Risk in an acute care setting.

This issue's WOC Nurse Consult focuses on ostomy care. Ostomy Section Editor Barbara Hocevar describes a case of an adult woman with a 5-month history of a peristomal ulcer. This new feature of the Journal is a must read because it reviews essential knowledge related to managing an ostomy in a patient with inflammatory bowel disease, as well as its emphasis on critical thinking as an essential component of WOC nursing care in any setting.

The Ostomy section opens with Kathryn Sloots, Lynne Bartlett, and Yik-Hong Ho who follow up their article from the previous issue of the Journal focusing on nursing management of postsurgery bowel dysfunction. You will want to read this article because it builds on the knowledge and clinical wisdom shared in their previous article while focusing on an essential skill for all advanced and expert continence nurses: pelvic floor muscle training. Consulting Editor Sandra Engberg, Susan Cohen, and Susan Sereika report a pilot study exploring the efficacy of acupuncture for managing urge and mixed urinary incontinence. While every continence nurse is aware that behavioral therapy, often administered in combination with antimuscarinic agents, is effective for most women experiencing urge and mixed urinary incontinence, effective interventions for women who prove refractory to these interventions remain a significant gap in our knowledge. You will want to read this article to remain knowledgeable of an ongoing, major research project designed to determine whether acupuncture might be an effective treatment option for this group and a viable alternative for women seeking acupuncture as first-line therapy.

In part 6 of their ongoing series in the Spotlight on Research feature of the Journal, Eileen Harwood and Elizabeth Hutchinson discuss how to manage data collected as part of a research study. This feature qualifies as a must-read article for any WOC nurse involved in or considering participating in a research study because it provides pragmatic and valuable knowledge and tips about physically managing data, a topic that is rarely covered in even detailed research design textbooks. As with previous articles, this series is especially valuable to WOC nurses because it not only provides essential knowledge but also illustrates this knowledge using studies previously published in the Journal.

In this issue's Getting Ready for Certification, Amy Schaffer provides 6 exemplar questions focusing on other wounds. You will want to read this regular feature of the Journal, not only because it provides questions you can use to familiarize yourself with the construction and various levels of questions that appear on certification examinations administered by the WOCNCB but also because it provides important information summarized from a presentation given by Donna Thompson at the 2009 WOCN National Conference that described how to use the board's content outline to focus your certification examination preparation.

Rose Murphree reports a case where allogenic acellular dermal matrix was used for the management of an enterocutaneous fistula in this issue's Challenges in Practice feature. You will want to read this informative and highly visual article to better understand how the dermal matrix is incorporated into surgical management of a patient with a significant abdominal wall defect and how the WOC nurse plays an essential role on the team providing care for these extremely complex and challenging patients.

Evidence From Other Publications

This Context concludes my exploration of single evidence- based documents or clinical practice guidelines. I have previously reviewed a major systematic review and meta-analysis focusing on pressure redistribution surfaces for the prevention or treatment of pressure ulcers, a best practice document for nursing management of patients with ostomies, and best practice for managing patients with enterocutaneous fistulae. In this issue, I will describe a reference text that combines integrative literature review with systematic review and ranking of evidence related to urinary and fecal incontinence. The International Consultation on Incontinence is arguably the most comprehensive academic reference for fecal and urinary incontinence in the world. Currently in its fourth edition,1 this 2-volume textbook represents the work of a number of committees charged with writing chapters that cover a wide variety of topics in both urinary and fecal incontinence. Chapter topics vary from basic sciences (Cell Biology, Neural Control, Pathophysiology of Urinary Incontinence, Fecal Incontinence, and Pelvic Organ Prolapse) to diagnostic testing (Dynamic Testing, Symptom and Quality of Life Assessment) to specific interventions and focused populations (Surgery for Urinary Incontinence in Women, The Obstetric Vesicovaginal Fistula in the Developing World, Conservative and Pharmacologic Management of Fecal Incontinence in Adults). Clinical evidence is ranked based on a 4-level system where level 1 indicates strong evidence, typically including systematic reviews and meta-analyses of multiple randomized clinical trials or several good quality randomized clinical trials. Level 2 evidence is described as randomized clinical trials with lower-quality or good-quality prospective comparison cohort studies (quasi-experimental studies). Level 3 evidence is characterized by good-quality retrospective case-control studies or good-quality case series. Level 4 evidence is described as "expert opinion." Recommendations for clinical practice arise from the various levels of evidence, and it is ranked in a 4-level Likert scale where Grade A clinical recommendations are "strongly recommended," grade B recommendations are "recommended," grade C recommendations are based on consensus from committee members and are best expressed as expert opinion, and grade D recommendations are described as "no recommendation possible." For the expert and advanced practice WOC or continence nurse, the incontinence textbooks are a must-have item. While the quality of chapters varies (common among academic references written using this process), it can be accurately described as the "encyclopedia" of incontinence and provides a wealth of important evidence-based summaries and clinical practice recommendations for the management of urinary and fecal incontinence that is unparalleled by any other single source.

2009 JWOCN Manuscript Award Winners

At the 2009 Annual Meeting of the WOCN, Cynthia Padula accepted the Clinical Manuscript Award for the paper Prevention and early detection of pressure ulcers in hospitalized patients. (Padula CA, Osborne E, Williams J. Prevention and early detection of pressure ulcers in hospitalized patients. Journal of Wound Ostomy & Continence Nursing. 35(1):66-75, January/February 2008). They described a quality improvement project designed to promote prevention and early detection of pressure ulcers in hospitalized patients, influencing daily practice and translating these changes into meaningful reductions in the incidence of hospital-acquired pressure ulcers.

Jane Fellows and Leanne Richbourg accepted the Research Manuscript Award for Ostomy pouch wear time in the United States. (Richbourg L, Fellows J, Arroyave WD. Ostomy pouch wear time in the United States. Journal of Wound Ostomy & Continence Nursing. 35(5):504-508, September/October 2008) for their report on a national survey of pouch wear time. The value of their findings was strengthened by a robust sample size (N = 551), the geographic diversity of respondents (84% of states represented), and the inclusion of persons living with fecal as well as urinary ostomies.

We congratulate these outstanding authors!!

Reference