Evaluation of the Impact of the Wound Treatment Associate (WTA) Education Program on Practice and Quality Patient Outcomes.

PURPOSE: The Wound Treatment Associate (WTA) program is an education offering of the WOCN Society. This evidence-based continuing education program prepares nurses to serve as a unit-based resource for nursing staff. The WTA program is approved by the American Nurses Credentialing Association (ANCC) for 32.25 contact hours and aimed at licensed health care personnel. This article focuses on the impact of this education program, in particular a reduction in hospital-acquired pressure injury (HAPI) in acute care and decrease in visits per episode (VPE) and supply costs in home health. METHODS: Surveys were sent to all course participants to date to fulfill the summative evaluation requirement for ANCC approval to determine the perception of improvement in knowledge, skills, and practice. An additional survey was developed and reviewed by members to send to WTA program course coordinators. RESULTS: Participants (n = 153) reported an increase in confidence in knowledge and skills about wound care and use in nursing practice. The number of respondents to the course coordinator survey was lower (n = 48). Coordinators did report a reduction in pressure injuries in acute care. Home health respondents noted a decrease in VPE and reduction in the cost of supplies. Data reported on abstracts and posters suggested positive impacts of pressure injury prevention programs in acute and home health care. CONCLUSIONS: Although there are limitations to the aforementioned reporting, incorporating the WTA program into pressure injury prevention programs and wound treatment programs showed a reduction in HAPIs in acute care and decreased VPE and supply costs in home health.

Do Prophylactic Foam Dressings Reduce Heel Pressure Injuries?

PURPOSE: The purpose of this evidence-based report card is to examine the evidence and provide recommendations related to the effectiveness of prophylactic foam dressings in reducing heel pressure injuries. QUESTION: Do prophylactic foam dressings applied to the heel reduce heel pressure injuries for patients in the acute care setting? SEARCH STRATEGY: A search of the literature was performed by a trained university librarian that resulted in 56 articles that examined pressure injury, prevention, and prophylactic dressings. A systematic approach was used to review titles, abstracts, and text, yielding 13 studies that met inclusion criteria. Strength of the evidence was rated based on the methodology from Essential Evidence Plus: Levels of Evidence and Oxford Center for Evidence-Based Medicine. FINDINGS: Thirteen studies were identified that met inclusion criteria; 1 was a randomized controlled trial, 2 were systematic reviews, 3 quasi-experimental cohort studies, 1 quality improvement study, 1 case series, 1 scoping review, 1 consensus panel, and 3 bench studies. All of the studies identified suggest that the use of prophylactic foam dressings reduces the development of pressure injuries on the heel when used in conjunction with a pressure injury prevention program. The strength of the evidence for the identified studies was level 1 (4 level A, 4 level B, and 5 level C). CONCLUSION/RECOMMENDATION: The use of prophylactic multilayer foam dressings applied to the heels, in conjunction with an evidence-based pressure injury prevention program, is recommended for prevention of pressure injuries on the heel (SORT level 1).

WOCN Society and AUA Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Urostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patient's independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Urologists and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Urological Association and the American Society of Colon and Rectal Surgeons, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

WOCN Society and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Colostomy or Ileostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patient's independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Colon and rectal surgeons and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Society of Colon and Rectal Surgeons and the American Urological Association, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

Collagenase for enzymatic debridement: a systematic review.

Debridement is an essential component of wound bed preparation. Various techniques of debridement are commonly used in clinical practice. This systematic review summarizes and ranks evidence concerning the safety and efficacy of the selective enzymatic debriding agent collagenase. Studies were identified comparing collagenase to inactive (sham) ointment and to alternate techniques for debridement including autolytic and surgical. A preponderance of evidence from this systematic review confirms that collagenase ointment is a safe and effective choice for debridement of cutaneous ulcers and burn wounds.

Is ultrasonic mist therapy effective for debriding chronic wounds?

BACKGROUND: Ultrasonic mist debridement uses acoustic energy to remove devitalized tissue from the wound bed and to promote wound healing. OBJECTIVES: We systematically reviewed the literature to determine whether ultrasonic mist therapy effectively removes necrotic debris from the bed of chronic wounds and promotes wound healing. SEARCH STRATEGY: A systematic review of electronic databases MEDLINE and CINAHL (from January 1996 to February 2008) was undertaken using the key words: (1) therapeutic ultrasound, (2) ultrasonic, and (3) ultrasonic mist. Prospective studies that compared ultrasonic mist therapy to a sham device, to another debridement technique, or to alternative treatments for wound healing were included. RESULTS: There is insufficient evidence to determine whether ultrasonic mist therapy effectively debrides necrotic tissue in chronic wound beds. Limited evidence suggests that noncontact, low-hertz frequency ultrasonic mist therapy promotes wound healing when used in conjunction with standard wound therapy. IMPLICATIONS FOR PRACTICE: Ultrasound treatment has been used on wounds associated with neuropathy, limb ischemia, venous insufficiency, trauma, as well as poorly healing surgical wounds. Few adverse effects have been noted. Pain, when reported, has been successfully addressed with topical analgesia.

State of the science: pathology and management of the patient with overactive bladder.

A relatively new term, overactive bladder is used to describe urinary frequency, urgency, and nocturia with or without urinary incontinence. Normal micturition involves coordination among the nervous system, the bladder, and the sphincter. Theories about pathogenesis include disorders of the central and peripheral nervous system, lowered levels of neurotransmitters, and structural problems of the bladder and sphincter. Assessing the patient with overactive bladder incorporates a thorough history and focused physical exam. Current treatments for this condition include lifestyle changes, behavioral interventions, pharmacologic management, and neuromodulation therapy. Research into different medications and delivery systems proves promising for the patient with overactive bladder.

Enzymatic wound debridement.

BACKGROUND: Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound. OBJECTIVES: We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing. SEARCH STRATEGY: A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included. RESULTS: Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea-based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing. IMPLICATIONS FOR PRACTICE: Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.