Inpatient Versus Outpatient Management of Negative Pressure Wound Therapy in Pediatric Patients.

BACKGROUND: Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients. MATERIALS AND METHODS: We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with ≤50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with >50% of NPWT. RESULTS: We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy. CONCLUSIONS: Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall cost-effective treatment setting for NPWT in the pediatric population.

Treatment of Dehisced, Thoracic Neonatal Wounds With Single-Use Negative Pressure Wound Therapy Device and Medical-Grade Honey: A Retrospective Case Series.

PURPOSE: The purpose of this study was to report on our experience with a portable, single-use negative pressure wound therapy device used in combination with activated active Leptospermum honey (ALH) in the treatment of colonized or infected, dehisced, thoracic wounds in neonates with complex congenital heart disease. DESIGN: Retrospective, descriptive study. SUBJECTS AND SETTING: We reviewed medical records of 18 neonates and reported on findings from 11; the remaining 7 were not included secondary to incomplete records, transfer to a different institution prior to wound healing, or death. The median age of our patients was 12 days (range, 2 days to 5 weeks); their mean gestational age was 34 weeks. All of the neonates had acquired postoperative wound dehiscence that were colonized or infected and were treated in the neonatal intensive care unit (NICU) at Cohen Children's Medical Center (New Hyde Park, New York), a regional perinatal center with a level 4 NICU. METHODS: Wound cultures were obtained on all patients prior to treatment commencement. All cultures were repeated on day 4 of treatment. Systemic antibiotics were administered as necessary. No complications were observed related to the use of negative pressure wound therapy device and ALH. All patients were followed until discharge home or transfer to another facility. The pain scores during placement and removal were acceptable (between 1 and 3; median = 2) using the Neonatal Infant Pain Scale. Staff and parents indicated that the combination of ALH and the negative pressure wound therapy device did not interfere with daily care and parental bonding. CONCLUSIONS: Use of ALH and a single-use negative pressure wound therapy device was successful in this series of 11 neonates with complex congenital heart disease.

Negative pressure wound therapy and nurse education.

BACKGROUND: there can be serious consequences for patients if negative pressure wound therapy (NPWT) is performed incorrectly and patient safety must be paramount. The existing literature was found to mainly concentrate on the use of the technology from the patient perspective. This article examines the opinions of nurses who apply the therapy. METHOD: five staff nurses from different areas with differing experience levels were interviewed in a semi-structured manner. The transcribed interviews were coded, sorted into themes and analysed. RESULTS: the themes were: enhancing knowledge and understanding, managing problematic pumps, formalised and interactive training, and efficacy and healing. There was a lack of standardised training provided for the nurses interviewed. Overall the nurses were aware of the basic evidence behind the treatment but would have liked additional support in this area as well as some practical, less pressured training. This complements the existing literature. CONCLUSION: nurses are expected to learn difficult and highly specialised skills quickly within a busy ward environment, often with no prior training or preparation. As things can go wrong, with the potential for patient harm, it is vital that nurses get these skills right first time, but it is difficult to do this in a practical, fast and cost-effective way. There is scope for future research in the area and perhaps the development of an online training tool to assist nurses in understanding and undertaking a new procedure.

Pain associated with negative pressure wound therapy.

Negative pressure wound therapy (NPWT) has emerged as an effective treatment option for a variety of complex wounds. However, pain is anecdotally a common side effect of NPWT affecting quality of life and even precluding some patients from continuing with the treatment. This literature review examines the evidence relating to pain management for patients undergoing NPWT with a view to identifying methods of administration that could minimise pain and allow more patients to benefit from the treatment. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), Embase and Medline databases were accessed to identify relevant studies. Ten studies were found that matched the review inclusion criteria. These demonstrate some potential areas for further research but more evidence is required before any recommendations can be made.

[Nursing process for patients treated with negative pressure therapy afther severe foottrauma]. / Proces sestrinske skrbi kod pacijenata lijecenih negativnim tlakom nakon teske ozljede stopala.

Foot injuries inflicted by firearms and high pressure washing machines cause distortion of psychophysical and biomechanical characteristics with decrease of ability to satisfy the basic human needs and existing mode of living. Treatment with negative pressure accelerates wound healing process and recovery. Nursing role is significant in all these problems, which arise as patient reaction to the severe trauma. With the extensive surgical procedures required and nursing intervention, the actual and potential patient problems are minimized or eliminated, as evidenced from the good functional and esthetic results, and resuming independence and usual daily activities.

Negative pressure wound therapy as an adjunct to compression for healing chronic venous ulcers.

OBJECTIVE: To determine the efficacy of negative pressure wound therapy (NPWT), when used in combination with compression bandaging, for healing chronic resistant venous ulcers. METHOD: In this pilot study, seven patients (with a total of 12 chronic resistant venous ulcers) received adjunctive NPWT and compression bandaging for 4 weeks. Their wounds were monitored for a total of 12 weeks. RESULTS: Dormant ulcers were seen to rapidly develop into healthy wounds, with a granulating base. CONCLUSION: This regimen may have a role in stimulating chronic venous ulcers into healing wounds, or in preparing them for skin grafting.

Use of a vacuum-assisted device in a neonate with a giant omphalocele.

Wound healing is a complex process that can be even more challenging in neonatal and pediatric patients. Infants and children have special characteristics such as skin immaturity, a high body surface to weight ratio, sensitivity to pain, increased potential for percutaneous absorption of medication, and an immature immune system that adds to the complexity of treating their wounds. The use of controlled topical negative pressure across a wound surface has been used in adults and children since 1995. Recently, the use of this device has been reported in neonates. This article discusses the normal process of wound healing and describes the use of this device in an infant with a giant omphalocele.

Repair of a huge vesicocutaneous fistula with the rectus femoris musculocutaneous flap and VAC.

Adequate drainage is a prerequisite for closing a vesicocutaneous fistula, but the continued exposure to urine makes this impossible. Here, VAC was successfully used as a preoperative therapy before flap transplantation.

Clinical and economic consequences of discharge from hospital with on-going TNP therapy: a pilot study.

Despite practical advantages (such as exudate management and reduced dressing changes) the adoption of topical negative pressure therapy (TNP) in home care may be restricted through logistical issues and a perception that the intervention is more expensive than the more traditionally utilised wound management products. This pilot study followed the experiences of 20 subjects with a variety of acute and chronic wounds who received TNP either in hospital (n=10), at home (n=5) or in both care settings (n=5). All except one subject showed both reductions in wound surface area and improved appearance of the wound bed during the course of treatment ranging from 2 to 74 days. The single subject, where a deterioration in their wound was noted, had presented with an unclear wound diagnosis thus highlighting the absolute need for accurate diagnosis of wound aetiology prior to commencement of any treatment regime. The cost of treatment was lower where subjects were treated at home (mean cost per day pound45.9 SD: 17.0) and highest where care was delivered exclusively in hospital (mean cost per day pound259.1 SD: 2.8). Direct comparison of these data with other published studies on the use of TNP therapies is obviously restricted through regional differences in the cost of nursing care, patterns of use of the TNP consumables and the wound outcomes followed in individual cases, however, there would appear to be a qualitative and economic benefit from home care.

Retrospective evaluation of clinical outcomes in subjects with split-thickness skin graft: comparing V.A.C.® therapy and conventional therapy in foot and ankle reconstructive surgeries.

This retrospective study compared the clinical outcomes of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum-Assisted Therapy(®) (V.A.C.(®) Therapy, KCI Licensing Inc., San Antonio, TX) to non-NPWT/ROCF conventional therapy (CT) in split-thickness skin graft (STSG) survival in all patients to determine whether NPWT/ROCF affects the outcome of the graft survival, in terms of overall graft take, duration of graft take, repeated grafts and complications. The authors conducted a 10-year retrospective review of 142 patients admitted to a level I trauma centre and treated with an STSG in foot and ankle reconstructive surgeries. Demographic data, wound etiology, dressing type used, time to graft take, NPWT/ROCF duration, complications and outpatient treatments were analysed. There were significantly fewer repeated STSGs required in the NPWT/ROCF group compared to CT [n = 3 (3·5%) versus n = 9 (16%); P = 0·006]. In assessing safety, there were fewer complications in graft failure (seroma, hematoma and infection) in the NPWT/ROCF group as compared to the CT group at 8·9 months (range: 1-12 months). NPWT/ROCF is an excellent alternative for securing an STSG and is associated with improved graft survival as measured by a reduction in the number of repeated STSGs and graft failure complications.

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds.

Negative pressure wound therapy is widely used in the treatment of hard-to-heal wounds; however, pain during dressing changes, which is often associated with pain on the commencement and cessation of pressure application and because of in-growth of new granulation tissue into interstices of foam dressings, is often experienced. Anecdotal reports have suggested that choice of gauze as the negative pressure wound therapy dressing may reduce the pain associated with dressing changes. A prospective, multi-center, non-comparative clinical investigation was carried out using gauze-based negative pressure wound therapy in chronic and acute wounds. Over 152 patients were evaluated. Median duration of therapy was 18 days with 91% of patients progressing towards healing at the end of therapy. Wound pain and odour were significantly reduced (P < 0.001) over the course of therapy. Wound pain during dressing changes was reported to be absent in 80% of dressing removals. No damage to the wound bed following dressing removal was observed in 96% of dressing changes. Dressing applications were considered easy in 79% of assessments and took a median of 20 min to complete. In patients susceptible to pain, gauze-based negative pressure therapy may be a viable option to maximise patient comfort.

Focus on negative pressure: exploring the barriers to adoption.

Recent government documents have identified the move from hospital-based care into the community and have suggested that more complex wound care can now be provided in the community setting with therapies such as negative pressure wound therapy (NPWT). This focus group interview explores community tissue viability specialists' experiences and attitudes towards the use of NPWT in community settings. The study was conducted in compliance with relevant ethical guidelines. Data analysis identified various themes but this paper concentrates on three; untimely referrals; cost implications and mutual benefit and understanding.

Patients' views on topical negative pressure: 'effective but smelly'.

Topical negative pressure (TNP) is increasingly being used in both the UK and internationally, on wounds of acute, chronic and surgical origin. However, little is known about patients' experiences of this therapy. NHS Quality Improvement Scotland undertook a health technology assessment on TNP in 2009-2010. This assessment considered clinical and cost-effectiveness, patient issues, and organizational issues. This article describes the primary research undertaken for the patient issues section. Qualitative methods were used to attempt to understand patients' perceptions and experiences of TNP. A focus group and individual interviews were held in Glasgow, recorded, and transcribed verbatim. Data were analysed thematically. The themes which emerged as being important to patients receiving TNP were healing, smell, embarrassment, pain, nurse training, self-care, information provision, getting out of hospital, and returning to normal life. Implications for practice are suggested for manufacturers, service leads and nurses.

Management of ileocutaneous fistulae using TNP after surgery for abdominal malignancy.

Enteric fluids produced by enterocutaneous fistulae can cause severe inflammation in the surrounding skin. By removing these corrosive fluids, topical negative pressure can help maintain skin integrity and promote spontaneous closure.

The role of community nurses in providing a seamless patient pathway.

Every day, community nursing teams deliver evidence-based practice and use their expertise to oversee complex care pathways. However, much of the valuable work community nurses undertake remains invisible or tacit as practitioners concentrate on managing their patients' needs rather than raising the profile of the service they offer. This case study demonstrates the crucial role a community nursing team played in coordinating services, risk management and delivering evidence-based care. This enabled an individual to heal his problematic abdominal wound and quickly regain his former quality of life. When community nursing teams apply their experience and clinical expertise, they can facilitate dramatic improvements in patients' health and recovery times. Nursing teams need to highlight and promote the valuable role they play in care pathways to the commissioners of community services. Patients can then continue to be supported by professionals with the experience and skills to assist them in managing complex clinical situations.