Debridement options for the interprofessional team.

ABSTRACT: Debridement is a core component of chronic wound management. Although various debridement methods exist, each carries a unique patient risk level. This article discusses the different normal tissue components that are critical to safe debridement practice, various methods of wound debridement for nurses, and the importance of an interprofessional team and consulting a wound specialist.

Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

GENERAL PURPOSE: To review a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize issues related to wound assessment.2. Identify a class of drugs for the treatment of type II diabetes mellitus that has been shown to improve glycemia, nephroprotection, and cardiovascular outcomes.3. Synthesize strategies for wound management, including treatment in resource-limited settings.4. Specify the target time for edge advancement in chronic, healable wounds.

Chronic wound management in low-resource settings deserves special attention. Rural or underresourced settings (ie, those with limited basic needs/healthcare supplies and inconsistent availability of interprofessional team members) may not have the capacity to apply or duplicate best practices from urban or abundantly-resourced settings. The authors linked world expertise to develop a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. A group of 41 wound experts from 15 countries reached a consensus on wound bed preparation in resource-limited settings. Each statement of 10 key concepts (32 substatements) reached more than 88% consensus. The consensus statements and rationales can guide clinical practice and research for practitioners in low-resource settings. These concepts should prompt ongoing innovation to improve patient outcomes and healthcare system efficiency for all persons with foot ulcers, especially persons with diabetes.

Protocol for the Development of the Fourth Edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline Using GRADE Methods.

ABSTRACT: The National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance are commencing a new (fourth) edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline . The fourth edition of the International Pressure Injury (PI) Guideline will be developed using GRADE methods to ensure a rigorous process consistent with evolving international standards. Clinical questions will address prevention and treatment of PIs, identification of individuals at risk of PIs, assessment of skin and tissues, and PI assessment. Implementation considerations supporting application of the guidance in clinical practice will be developed. The guideline development process will be overseen by a guideline governance group and methodologist; the guideline development team will include health professionals, educators, researchers, individuals with or at risk of PIs, and informal carers.This article presents the project structure and processes to be used to undertake a systematic literature search, appraise risk of bias of the evidence, and aggregate research findings. The methods detail how certainty of evidence will be evaluated; presentation of relative benefits, risks, feasibility, acceptability, and resource requirements; and how recommendations will be made and graded. The methods outline transparent processes of development that combine scientific research with best clinical practice. Strong involvement from health professionals, educators, individuals with PIs, and informal carers will enhance the guideline's relevance and facilitate uptake. This update builds on previous editions to ensure consistency and comparability, with methodology changes improving the guideline's quality and clarity.

Current Perspectives on Pressure Injuries in Persons with Dark Skin Tones from the National Pressure Injury Advisory Panel.

BACKGROUND: Pressure injury (PI) development is multifactorial. In patients with dark skin tones, identifying impending PIs by visual skin assessment can be especially challenging. The need for improved skin assessment techniques, especially for persons with dark skin tones, continues to increase. Similarly, greater awareness of the need for inclusivity with regard to representation of diverse skin colors/tones in education materials is apparent. OBJECTIVE: To provide current perspectives from the literature surrounding skin assessment and PI development in patients with dark skin tones. METHODS: The following elements will be discussed through the lens of skin tone: (1) historical perspectives of PI staging from the National Pressure Injury Advisory Panel, (2) epidemiology of PI, (3) anatomy and physiology of the skin, (3) skin tone assessment and measurement, (4) augmented visual assessment modalities, (5) PI prevention, (6) PI healing, (7) social determinants of health, and (8) gaps in clinician education. CONCLUSIONS: This article highlights the gap in our clinical knowledge regarding PIs in patients with dark skin tones. Racial disparities with regard to PI development and healing are especially clear among patients with dark skin tones. Skin tone color assessment must be standardized and quantifiable in clinical education, practice, and research. This work is urgently needed, and support from private and governmental agencies is essential.

Skin and wound care survey: 2019 results.

ABSTRACT: This article presents the 2019 Skin and Wound Survey results, which could assist in identifying gaps in nurses' skin and wound care knowledge and in developing nursing curricula and continuing professional development. The 2019 survey was conducted before the COVID-19 pandemic, and the results are compared with those from surveys conducted in 2004 and 2012. Author commentaries and additional input from the survey participants are also provided.

Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group.

OBJECTIVE: Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction. METHODS: An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds. RESULTS: Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention. CONCLUSIONS: The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.

Debridement: Technical Considerations and Treatment Options for the Interprofessional Team.

GENERAL PURPOSE: To enhance the learner's chronic wound debridement competence as an interprofessional team member. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Differentiate healable, maintenance, and nonhealable wounds to create a holistic debridement treatment plan using the Wound Bed Preparation paradigm.2. Evaluate active debridement options including the potential need for an interprofessional referral or specialized investigations.3. Assess chronic wound debridement options.4. Analyze case studies for appropriate clinical application of debridement modalities.

Debridement is a critical component in the management of both acute and chronic wounds. Six reviewed methods of debridement exist, and specific techniques are more appropriate to match patient needs with available clinical resources. Accurate differentiation between healable, maintenance, and nonhealable wounds is paramount when determining whether a wound would benefit from debridement. Clinical assessment includes review of the patient's underlying medical conditions/ previous surgeries along with the history and progression of the wound. Awareness of the physiologic wound bed preparation components that contribute to the current wound status will direct treatment of the abnormal components. Optimal wound status includes complete healing or reduced abnormal wound-related symptoms or signs. Debridement competency requires an awareness of the six types of debridement, their clinical utility, and appropriate patient selection. Providers need to assess patients' wounds, triage them, and refer them as necessary to an interprofessional setting. For stalled but healable wounds, specialized testing may be necessary when managing patients who would benefit from more invasive or advanced forms of wound care. This article informs providers on the training and experience required for specific debridement techniques depending on the wound etiology.

Results of the 2022 Wound Survey on Skin Failure/End-of-Life Terminology and Pressure Injuries.

OBJECTIVE: To summarize the major findings of a survey first conducted in 2019 and repeated in 2022 and review new concepts (angiosomes and pressure injuries) and challenges due to the COVID-19 pandemic. METHODS: This survey captures participants' ranking of agreement or disagreement with 10 statements on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable/avoidable pressure injuries. The survey was hosted online by SurveyMonkey from February 2022 until June 2022. All interested persons were able to participate in this voluntary, anonymous survey. RESULTS: Overall, 145 respondents participated. The same nine statements achieved at least 80% agreement (somewhat agree or strongly agree) as in the previous survey. The one statement that did not reach consensus also failed to reach consensus in the 2019 survey: "The concept of skin failure does not include pressure injuries." CONCLUSIONS: It is the authors' hope that this will stimulate more research into terminology and etiology of skin changes in persons at end of life and encourage more research regarding terminology and criteria to define which skin lesions are unavoidable or avoidable.

Early Malignant Melanoma Detection, Especially in Persons with Pigmented Skin.

GENERAL PURPOSE: To present a comprehensive gap analysis of podiatric melanoma literature. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Select the appropriate assessment techniques for screening patients, especially those with skin of color, for melanoma.2. Compare and contrast the various types of melanoma.3. Discuss the results of the literature review that offer insight to clinicians screening patients for melanoma.

Early detection of malignant melanoma is associated with better survival and clinical outcomes. Visual skin inspection is part of melanoma lesion assessment, but clinicians often have difficulty identifying lesions in persons with darker skin tones (eg, Fitzpatrick type 5 [brown] and type 6 [black] skin). There is also a lack of knowledge about the skin sites that are best to evaluate in persons with darkly pigmented skin (eg, the plantar surface of the feet, palms of the hand, and under the nail plate). These limitations can lead to a delay in diagnosis with potentially poor prognostic outcomes. In this article, the authors identify relevant literature to increase awareness for the presence of early signs of malignant melanoma in all skin types. Patient empowerment includes lifestyle adaptations, such as conducting regular skin and foot self-examinations to detect melanoma signs and applying sun protection on feet.

Medical Device-Related Pressure Injury to the Ear from a Mask.

ABSTRACT: Mask wearing is now ubiquitous because of the COVID-19 pandemic and has given rise to medical device-related pressure injuries in persons at risk of skin breakdown. The ear has unique anatomy that is particularly susceptible to injury from pressure. In this time of mandatory personal protective equipment requirements in healthcare facilities, protection and assessment of skin in the vulnerable postauricular area are needed. This article presents a case report of a pressure injury on the ear, reviews the anatomy of the ear, and provides strategies for assessment and treatment of pressure injuries in this often overlooked anatomic region.

Practice Implications from the WCET® International Ostomy Guideline 2020.

GENERAL PURPOSE: To introduce the 15 recommendations of the International Ostomy Guideline (IOG) 2020, covering the four key arenas of education, holistic aspects, and pre- and postoperative care; and to summarize key concepts for clinicians to customize for translation into their practice. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Analyze supporting evidence for the education recommendations in the IOG 2020.2. Identify a benefit of the International Charter of Ostomate Rights.3. Distinguish concepts related to pre- and postoperative ostomy-related care.4. Select a potential barrier to IOG 2020 guideline implementation.

The second edition of the WCET ® International Ostomy Guideline (IOG) was launched in December 2020 as an update to the original guideline published in 2014. The purpose of this article is to introduce the 15 recommendations covering four key arenas (education, holistic aspects, and pre- and postoperative care) and summarize key concepts for clinicians to customize for translation into their practice. The article also includes information about the impact of the novel coronavirus 2019 on ostomy care.