In This Issue of JWOCN

The first issue of 2010 continues the Journal's trend of covering a wide range of topics in a single issue as well as reflecting our global reach. Last year, Lee Ann Krapfl wrote about evolving changes in the Centers for Medicare & Medicaid Services (CMS) in acute care facilities. Those changes seemed sufficiently momentous at the time to rivet our attention for several years to come. However, as historical events often prove, shifts in CMS policy were merely a prelude to a national debate on reforming healthcare delivery in the United States, now the center of a lively, and sometimes contentious, national conversation. In this issue's View From Here, Lee Ann again provides a well-reasoned and succinct overview of those issues that are most likely to influence WOC practice. You will want to read her feature for an unbiased description of the most important issues being debated in congress, and because it provides rational predictions about the probable outcome.

This issue's Spotlight on Research provides a succinct and accessible review of the concept of power and its application to evidence-based practice. Sandra Engberg (Consulting Editor for the Journal) and Elizabeth A. Schlenk present a fictitious study comparing 2 different dressings for the treatment of stage III pressure ulcers. The results of the study show no difference, but Engberg and Schlenk offer you a means to look behind the veil of this conclusion to determine whether the study had sufficient power to truly answer the question it poses. This article is a great review for those who know all about this recurring challenge to the interpretation of study findings and it is a must-read article for those who may not be sure what the term power really means in the context of evidence-based practice.

This issue's Wound Care section opens with a state-of-the-science review of wound nitric oxide as a potential diagnostic marker for the treatment of diabetic foot ulcers. It is this issue's CE article. Joseph Boykin provides a thorough and masterful integrative literature review of the role of nitric oxide in wound healing, and diabetic foot ulcers in particular. This article qualifies as another must-read because it provides insight into an emerging indicator of the readiness of diabetic foot ulcers for advanced wound care therapies such as topical growth factors or bioengineered skin substitutes.

In the Journal's growing collection of articles focusing on pressure ulcer prevention, Abby Denby urges colleagues to remember that prevention starts in the emergency department. You will want to read this lucid description of a pilot program for preventing pressure ulcers among the growing number of patients admitted to hospital directly from its emergency department.

Teresa J. Kelechi, Ashlee Watts, and Jan Wiseman describe the strategies and costs associated with recruiting subjects for a randomized clinical trial evaluating the effect of cryotherapy on venous disorders. Whether you practice in a clinical setting and are attempting to encourage patients to adopt a novel technology for care, or you are involved in clinical research, you will want to read this article to learn new strategies for identifying and recruiting patients for a clinical trial.

Marjorie Groom, Ronald Shannon, Debashish Chakravarthy and Cynthia Fleck report the results of a quasi-experimental study of the effects of a nutrient-based skin program on the prevention of skin tears in a vulnerable nursing home-based population. While most WOC nurses are well aware of existing evidence supporting the need for a structured skin care program to prevent incontinence associated dermatitis and hospital-acquired pressure ulcers, the influence of care on the prevention of skin tears is less well known. You will want to read this article to gain insight into the effect of a structured skin regimen on skin tears and the potential cost savings associated with an effective prevention program.

If you practice in the home care setting and take care of patients with wounds, the work reported by Canadian colleagues Linda Baich, Donna Wilson, and Greta G. Cummings is both timely and encouraging. These authors systematically reviewed the literature and identified evidence that the presence of a WOC nurse reduces the number of visits, promotes successful wound healing, reduces hospital and emergency department readmission, and reduces cost. The evidence revealed in this article is essential to documenting the value of WOC nursing in this era when an economic recession, combined with growing healthcare costs and a national debate about reform, has forced all providers to seek evidence documenting their value in terms of both quality and cost.

In this issue's Ostomy Care section, Robin Gemmill, Virginia Sun, Betty Ferrell, Robert Krouse and Marcia Grant examine health-related quality of life in patients living with a urostomy. You will want to read this robust study to gain insights into the ongoing issues that challenge quality of life in a group who have lived with urinary diversions for an average of nearly 10 years.

This issue's Continence Care section opens with a research report from Kristina Patel, Donna Bliss and Kay Savik that examines health literacy in patients with fecal incontinence. While the title of this article may seem academic, its content is clinically relevant to any WOC nurse because it focuses on the language that patients use when describing fecal incontinence to healthcare providers, and the disparity in how they describe this common symptom as compared to the term we commonly employ.

Australian colleagues Winsome St. John, Marianne Wallis, Susan Griffiths and Shona McKenzie completed an integrative literature review of self-care strategies for managing urinary incontinence (UI). You will find this article especially valuable because it focuses on the containing, restricting, concealing, and modifying strategies and behaviors that persons living with UI employ on a daily basis.

This issue's Clinical Challenges deals with an issue previously considered in a View From Here, Dakin's Solution.1 Patricia Cornwell, Mary Arnold-Long, Stephanie Bernahl Barss, and Myra Varnado challenge the popular view that Dakin's solution should be avoided in topical wound therapy because of its potential cytotoxicity. Instead, they provide both an integrative literature review, backed up by 5 pertinent case studies that demonstrate both the feasibility of the treatment and positive outcomes after thoughtful application of varying concentrations of Dakin's solution in selected cases when the goals of wound therapy shifted from healing or palliative care to the management of exudate, pain, and odor. You will want to read this masterful Clinical Challenges to gain insights from the authors' blend of critical thinking skills and the application of existing evidence to determine appropriate uses of Dakin's solution in topical wound therapy, as well as Myra Varnado's accompanying commentary related to its value in a triage and immediate care setting following hurricane Katrina.

This issue's Getting Ready for Certification feature focuses on continence. You will want to read this feature because it provides an excellent opportunity to practice answering certification-level questions associated with continence care, as well as learning about some proven strategies to reduce the anxiety often associated with completing this aspect of full scope certification. In addition to these resources, author Amy Schaffner also shares basic facts about this section of the certification examination, providing additional insights into how to best prepare for this important but often feared component of certification.

Evidence From Other Publications

WOUND CARE

Although complications directly associated with a chronic wound are rarely the direct cause of death, WOC nurses have long recognized that a predisposition for developing chronic wounds is a harbinger of declining health. In a recent issue of Diabetes Care, Sohn and colleagues2 reported a retrospective review of 1,050 patients with either diabetes mellitus alone, diabetes mellitus plus Charcot arthropathy alone, or diabetes mellitus with Charcot arthropathy and a diabetic foot ulcer. As anticipated, patients with Charcot arthropathy had higher mortality rates over a 5-year period than those with diabetes alone (18.8% vs 28.3%). In addition, persons with Charcot arthropathy plus a diabetic foot ulcer had an even higher mortality rate (37.0%). Multivariate Cox proportional hazards ratio showed that both Charcot arthropathy and occurrence of a diabetic foot ulcer act as independent risk factors for death within a 5-year period. While these persons did not tend to die of complications directly associated with a diabetic foot ulcer or Charcot arthropathy, these findings suggest that these conditions act as harbingers of evolving peripheral vascular and macrovascular disease indicating declining health and a higher risk for mortality.

OSTOMY CARE

Selecting between a continent urinary diversion (continent cutaneous diversion or orthotopic neobladder) is ideally based on multiple factors, including the clinical characteristics of the underlying malignancy, the patient's overall health, and patient preference. In a recent issue of the World Journal of Urology, Gore and Litwin4 reported on more than 35,000 subjects who underwent either continent urinary diversion or ileal conduit for management of bladder cancer. Persons who underwent continent urinary diversion tended to be younger, male, privately insured, and treated by a surgeon at an urban teaching hospital when compared to patients who underwent an incontinence urinary diversion (ileal conduit). While the number of continent urinary diversions continues to rise, these data provide a sobering reminder of existing disparities of care in the United States related to geographic as well as economic access that must be addressed as we struggle to reform our healthcare system into one that better serves all Americans while preserving and fostering the highest quality possible.

CONTINENCE CARE

The association between depression and UI is well established. However, much less is known about the nature of this relationship, and some researchers suggest that depression, which is associated with a deficit of serotonin in the brain, may cause detrusor overactivity and urge UI, rather than an emotional response to the presence of any form of incontinence.3 Nuotio and coinvestigators5 recently reported on a retrospective comparison cohort study that sought to determine, among other things, risk factors for UI among persons aged 70 years and older at baseline who were followed for a period of 6 years. Among other factors, a depressive mood (assessed using the short form of the Geriatric Mood Scale) was found to be associated with an increased incidence of urge UI. The authors also speculate that depression may act as an independent risk factor for overactive bladder dysfunction and urge UI. Although additional evidence is needed before the precise nature of this relationship is defined, these findings provide more circumstantial evidence that depression may act as a cause, rather than a consequence, of UI.

References