Wound irrigation versus swabbing technique for cleansing noninfected chronic wounds: A systematic review of differences in bleeding, pain, infection, exudate, and necrotic tissue.

PURPOSE: To systematically summarize and review the existing literature to determine the difference between wound cleansing techniques, irrigation and swabbing, in relation to bleeding, pain, infection, necrotic tissue and exudate in non-infected chronic wounds including pressure injuries, venous and arterial leg ulcers and diabetic foot ulcers. METHODS: A systematic search of the electronic databases Ovid Medline, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EMBASE was performed to identify all relevant literature in English. The search also included systematic reviews as a method to obtain additional potential citations by manually searching the reference lists. Included studies were assessed for methodological quality using the Cochrane Risk of Bias Tool. RESULTS: One study met eligibility criteria. Two hundred fifty six patients with wounds healing via secondary intention (n = 256) were included. Wound cleansing via swabbing technique was associated with increased perception of pain and increased rates of infection when compared to the irrigation group (93.4% versus 84.2% p = 0.02 and 5.2% versus 3.3% p = 0.44, respectively). Only a small proportion of this sample met the inclusion criteria, so the results are not considered externally valid. CONCLUSION: Wound cleansing remains a controversial topic. Despite calls for further research, there continues to remain a large gap in evidence to guide practice. Irrigation continues to replace swabbing in the management of chronic wounds, although evidence of improved outcomes is virtually nonexistent. Although the one study identified was of sound methodological quality, chronic wounds accounted for only a small percentage of the sample. Therefore, results are not generalizable to those with chronic wounds. Further research is needed to determine the effectiveness of basic wound cleansing techniques before considering more costly products.

Formal Caregiver Experiences of Caring for Individuals at Risk for or with a Pressure Injury: A Metasynthesis.

OBJECTIVE: To explore formal caregiver experiences caring for patients with a pressure injury (PI) or who are at risk of developing a PI. DATA SOURCES: In November 2019, the researchers searched CINAHL (Cumulative Index to Nursing and Allied Health Literature) and MEDLINE databases for articles related to caregivers and their experiences with PI prevention and care. STUDY SELECTION: Twenty-eight qualitative studies were included in this review. DATA EXTRACTION: Literature was graded and critiqued with regard to design and research quality and then synthesized utilizing a narrative approach. DATA SYNTHESIS: Four themes were found within the literature: knowledge and education, environment and resources, collaboration and role clarity, and risk assessment. CONCLUSIONS: Across healthcare settings, formal caregivers noted the importance of effective PI knowledge and education. Recognizing both barriers and facilitators to PI prevention and management within the healthcare environment can help decision-makers make informed choices to improve PI management within their settings. In addition, developing interprofessional team skills and relationships, rather than practicing in silos, may have an impact on PI management. Although there are many interventions that reduce PI risk and assist in the management of PIs, not every intervention is appropriate for every healthcare setting. Clinician education on PIs, along with new interventions, could significantly impact the effectiveness of patient care.

Executive Summary: Debridement: Canadian Best Practice Recommendations for Nurses Developed by Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC).

Debridement is described in the literature as having a high level of clinical risk and may result in patient harm when performed by untrained nurses. As a result, specialized knowledge, skills, and competencies are required to initiate, direct, and perform safe and effective debridement. This executive summary provides an overview of Debridement: Canadian Best Practice Recommendations for Nurses from the Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC). The primary objective of these recommendations is to positively influence patient outcomes and enhance safety. The 12 recommendations place the safety of the patient and nurse at the forefront and highlight the educational, competency, certification, preceptor/mentorship, and legal requirements for nurses to initiate, direct, and perform all methods of debridement. We designed these recommendations to be circulated and implemented widely by nurses of various professional levels across the continuum of care and advocate for organizations and government agencies to clearly define debridement in their policies and legislative regulations.

Risk Factors Associated with Skin Tear Development in the Canadian Long-term Care Population.

BACKGROUND: Skin tears (STs) are prevalent wounds found in aging populations and in particular among those living in long-term care (LTC) settings. They are often misunderstood as expected outcomes of aging and as a result are frequently underrecognized and undertreated. Although many factors have been associated with ST development, there is little evidence to corroborate their roles as ST risks. OBJECTIVE: To examine the risk factors associated with ST development in the Ontario LTC population. METHODS: A prospective study design was used to explore the risk factors associated with ST development. A total of 380 individuals 65 years or older from four LTC facilities in Ontario were examined for STs at the beginning of the study and at week 4 to determine if STs had occurred. RESULTS: The study found an ST prevalence of 20.8% and an incidence of 18.9%. History of an ST at baseline (relative ratio [RR], 1.84; 95% confidence interval [CI], 1.25-2.70; P = .002); the presence of skin changes associated with aging, ecchymosis, and hematomas (RR, 1.60; 95% CI, 1.43-1.79; P < .001); chronic disease (RR, 1.17; 95% CI, 1.03-1.32; P = .018); requiring assistance with activities of daily living (RR, 1.13; 95% CI, 1.08-1.18; P < .001); and displaying aggressive behavior (RR, 1.06; 95% CI, 1.02-1.10; P = .001) were key risk factors associated with ST development. CONCLUSIONS: These results provide much needed Ontario data on the risk factors associated with ST development and can be used to support prevention programs mitigating ST risk.

Healing Rates of Venous Leg Ulcers Managed With Compression Therapy: A Secondary Analysis of Data.

PURPOSE: The purpose of this study was to explore average time to heal for patients with venous leg ulcers (VLUs) receiving standard of care that included compression and advanced wound dressings. DESIGN: Secondary analysis of an existing electronic database. SUBJECT AND SETTINGS: A convenience sample consisting of 1323 patients with VLUs from various community care sectors (homecare and clinics) across Canada. METHODS: The Wound Studies database used in the analysis consisted of data from 6 studies conducted prospectively between 1999 and 2009 in which the treatment and delivery of care for all lower leg ulcers (venous, arterial, and mixed) in Canada was examined. From these studies, only patients with VLUs, with an ankle-brachial pressure index of greater than 0.8, and surface area measurements of the ulcers at baseline, 3 months, and 6 months were included. Descriptive statistics were used to determine the proportion of patients who achieved closure at 3 and 6 months and explore the weekly and monthly healing rates for those who did and did not achieve closure. Logistic regression analysis was performed to identify predictive factors for healing. RESULTS: A total of 777 patients (mean age 69 years) met inclusion criteria. The proportion of patients who achieved closure at 3 and 6 months was 42.2% and 48.6%, respectively. Of the participants who achieved wound closure, monthly mean healing rate, measured by percentage of reduction in surface area, was 33.4% (0.56 cm, SD 1.4 [median 0.15 cm]) through month 3, and 31.0% (0.70 cm, SD 1.6 [median 0.08 cm]) through month 6. The overall monthly surface area reduction was 30%. CONCLUSION: Study findings suggest a monthly surface area reduction of 30% provides a baseline healing rate for VLUs managed with compression therapy and advanced dressings. Findings also suggest standard of care is not sufficient for healing in over 50% of the population, as the proportion of those who achieved closure at 3 and 6 months was 42.2% and 48.6%, respectively.

Skin tear prevalence and incidence in the long-term care population: a prospective study.

OBJECTIVE: The World Health Organization estimates that between 2015 and 2050 the proportion of the world's population over 60 years old will nearly double from 12% to 22%. An often overlooked byproduct of ageing is the skin changes associated with it, which heighten the risk of developing skin tears. Despite this presumed increased risk, the true impact of skin tears across age groups and care settings is poorly understood. The purpose of the present study was to establish the prevalence and incidence of skin tears in the Ontario long-term care population. METHOD: A prospective study design was used to explore the prevalence and incidence of skin tears. Individuals from four long-term care facilities in Ontario were followed over four weeks. The participants were examined for skin tears at the beginning of the study and at week four to determine whether skin tears had occurred and to record the skin tear type and location. RESULTS: A total of 380 individuals, aged 65 years and over, took part. The study found a skin tear prevalence of 20.8% and an incidence of 18.9% within four weeks. These results provide much needed data on the burden of skin tears in the long-term care population. Conclusion: The present study is an important first step towards developing a prevention programme targeting individuals at risk for skin tears in long-term care.

French Canadian translation and the validity and inter-rater reliability of the ISTAP Skin Tear Classification System.

OBJECTIVE: To adapt the International Skin Tear Advisory Panel (ISTAP) skin tear classification system into French Canadian, and to test the content validity and inter-rater reliability of the translated version. METHOD: Phase one included the translation of the ISTAP skin tear classification system into French Canadian, using a forward-back translation method. Following this the translated version was tested for content validity and inter-rater reliability with registered nurses from a French acute care hospital in Ottawa, Canada. RESULTS: The French Canadian translation of the ISTAP skin tear classification system was evaluated by 92 nurses without in-depth wound care training. The adapted version obtained a substantial level of agreement between users, (Fleiss' Kappa = 0.69). CONCLUSION: The study tested the content validity and inter-rater reliability of the French Canadian version of the ISTAP skin tear classification system. The results support previous studies and further validate the classification system as a reliable method for classifying skin tears. The study supports ISTAP's goal of establishing a global language for describing and documenting skin tears.

Medication Knowledge Among Older Adults Admitted to Home Care in Ontario During 2012-2013.

BACKGROUND: Medication use among Canadian seniors is widespread and increases with the number of comorbidities. Limited evidence exists on medication knowledge among seniors, especially in home care. PURPOSE: The purpose of this retrospective cohort study was to describe medication knowledge and ability to take medication among seniors admitted to home care in Ontario. RESULTS: Ten percent had little or no knowledge of what medication to take (n = 1,389/14,004) or an understanding of the purpose of their medications (n = 1,396/14,004). Increasing numbers of medications prescribed was associated with decreased knowledge of medications. The strongest predictor of limited knowledge and ability to take medication was dementia (odds ratio > 5.0). DISCUSSION: Among Ontario seniors living at home, knowledge about medications decreases as the number of medications increases. Therefore, this group may be at high risk of medication errors. CONCLUSION: Better systems are required to allow healthcare professionals to review with patients, any medications with patients and caregivers, to assist in addressing the decreased knowledge of medications. Such a system would provide the capacity to target those individuals at high risk for a medication error, as well as the medications and drug-drug interactions that seem most likely to be harmful among older adults.

Management of Moisture-Associated Skin Damage: A Scoping Review.

BACKGROUND: Protecting the skin against moisture-associated damage is an important component of comprehensive skin and wound care. Based on a review of literature, the authors propose key interventions to protect and prevent damage in the skin folds, perineum, and areas surrounding a wound or stoma. OBJECTIVE: The aim of this scoping review is to identify and provide a narrative integration of the existing evidence related to the management and prevention of moisture-associated skin damage (MASD). METHODS: Study authors searched several databases for a broad spectrum of published and unpublished studies in English, published between 2000 and July 2015. Selected study information was collated in several different formats; ultimately, key findings were aggregated into a thematic description of the evidence to help generate a set of summative statements or recommendations. RESULTS: Based on inclusion criteria, 37 articles were considered appropriate for this review. Findings included functional definitions and prevalence rates of the 4 types of MASD, assessment scales for each, and 7 evidence-based strategies for the management of MASD. CONCLUSIONS: Based on this scoping review of literature, the authors propose key interventions to protect and prevent MASD including the use of barrier ointments, liquid polymers, and cyanoacrylates to create a protective layer that simultaneously maintains hydration levels while blocking external moisture and irritants.

A prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection.

The objective of this prospective, non-randomised study was to evaluate the performance of an antibacterial foam dressing containing methylene blue and gentian violet (Hydrofera Blue Classic dressing® ) for the management of chronic wounds with local infection. Patients in this study were ≥18 years of age (n = 29), and each had at least one chronic wound ≥1 cm2 in size that showed signs of localised infection or critical colonisation but with good potential for healing based on clinical assessment. To all of these wounds, the dressing was applied and changed three times per week over the 4-week study period. The primary endpoints of the study were: (i) changes in wound surface area measurement, (ii) changes in Pressure Ulcer Scale for Healing (PUSH) scores, (iii) changes in percent surface area of devitalised tissue (i.e., yellow slough or other necrotic tissue) and (iv) changes in clinical signs associated with localised wound infection/critical colonisation. Participants were evaluated at presentation (week 0 = baseline), week 2 and at week 4 (end of the study). The 29 patients completed the study, and at week 4, the following wound improvements were observed: (i) baseline mean wound surface area was significantly reduced by 42·5%, from 21·4 to 12·3 cm2 at week 4 (P = 0·005); (ii) baseline mean PUSH score decreased significantly from 13·3 to 10·7 at week 4 (P < 0·001); (iii) baseline mean wound coverage by devitalised tissue (%) was significantly reduced, from 52·6 % to 11·4% at week 4 (P < 0·001) and (iv) the mean UPPER and LOWER wound infection scores were reduced from 3·6 at baseline to 0·9 at week 4 (75%; P < 0.001). These results indicate that the Hydrofera Blue Classic dressing was effective at managing these chronic wounds and helped them progress onto a healing trajectory.

Clinical Characteristics of Mixed Arteriovenous Leg Ulcers: A Descriptive Study.

PURPOSE: The purpose of this study was to identify the clinical characteristics of mixed arteriovenous leg ulcers (MLU) that differentiated them from venous leg ulcers (VLU). DESIGN: Secondary analysis of data from larger electronic database. SUBJECTS AND SETTING: The sample comprised 1007 persons with lower extremity ulcers. Two hundred sixty three individuals with MLU were compared to 744 individuals with VLU; their ankle brachial indices were 0.51-0.90 and 0.91-.30 respectively. Subjects were drawn from community care settings from across Canada. METHODS: Data concerning baseline demographic and pertinent clinical characteristics including ulcer history were collected using multiple validated instruments. The Leg Ulcer Assessment Tool was used to collect demographic and pertinent medical history, The Short Form Health Survey 12 and the Euro Wuol 5D (EQ-5D) were used to measure health related quality of life, the numeric pain scales was used to measure character and intensity of pain. Groups were compared using χ or Mann-Whitney U. RESULTS: Individuals with MLU were significantly older, has lower body mass index, a history of smoking, and more comorbid conditions than subjects with VLU. In many cases, clinical presentation was indicative of significant arterial insufficiency including cool extremities, shiny, cracked and inelastic skin, impaired capillary refill, and weak pedal pulses. Ulcer pain was highly prevalent, but overall pain rating was similar between groups. Mixed arteriovenous leg ulcers were associated with lower health related quality of life, greater mobility impairments, and more deficits in self-care and usual activities. CONCLUSION: Greater knowledge and understanding of the distinct characteristics of MLU is critical for appropriate screening, prevention, assessment and management of persons with this form of leg ulcer. Pain and health related quality of life factors are important considerations when evaluating and managing these patients.

Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data.

This is a prospective cohort study using population-level administrative data to describe the scope of pressure ulcers in terms of its prevalence, incidence risk, associating factors and the extent to which best practices were applied across a spectrum of health care settings. The data for this study includes the information of Ontario residents who were admitted to acute care, home care, long term care or continuing care and whose health care data is contained in the resident assessment instrument-minimum data set (RAI-MDS) and the health outcomes for better information and care (HOBIC) database from 2010 to 2013. The analysis included 203 035 unique patients. The overall prevalence of pressure ulcers was approximately 13% and highest in the complex continuing care setting. Over 25% of pressure ulcers in long-term care developed one week after discharge from acute care hospitalisation. Individuals with cardiovascular disease, dementia, bed mobility problems, bowel incontinence, end-stage diseases, daily pain, weight loss and shortness of breath were more likely to develop pressure ulcers. While there were a number of evidence-based interventions implemented to treat pressure ulcers, only half of the patients received nutritional interventions.

The Effectiveness of Topical Polyhexamethylene Biguanide (PHMB) Agents for the Treatment of Chronic Wounds: A Systematic Review.

INTRODUCTION: This is the first systematic review to explore the evidence on PHMB and determine how effective this topical agent is for the treatment of chronic wounds. MATERIALS AND METHODS: PubMed, Ovid MEDLINE, CINAHL, Embase, the Cochrane library, and Scopus were searched for relevant articles published from 1946 to February 3, 2014, with no restrictions on publication status. ProQuest was searched for relevant dissertations, editorials, and conference abstracts. Non-indexed journals were searched and companies that manufacture wound care materials containing PHMB were contacted for unpublished data. Only randomized controlled trials available in English were included. Bias was assessed using the CONSORT document for all included studies. After inclusion and exclusion criteria were determined, four reviewers (ET, SK, SG, RD) independently reviewed each title and abstract of the literature search results to determine whether the paper should be included for this review. When disagreements on study inclusion emerged, reviewers resolved them through discussion. RESULTS: Of the 1,725 articles identified in the search, 6 met inclusion criteria. Four studies reported wound healing. Two of these studies evaluated changes in wound surface area and the other two evaluated wound bed evolution with variable results. In five studies, participants randomly assigned to PHMB topical agents showed significant improvement in bacterial control compared to control groups. Five studies reported pain reduction from the use of PHMB agents. DISCUSSION: There were a small number of eligible studies found, but the interventions, outcome measures, and outcome reporting varied greatly, making meta-analysis impossible. PHMB agents were shown to promote healing and reduce pain more effectively than control treatments. CONCLUSION: The existing evidence shows that topical PHMB may promote healing of chronic stalled wounds, reduce bacterial burden, eliminate methicillin-resistant staphylococcus aureus (MRSA), and alleviate wound-related pain.

Knowledge, Attitude, and Practice in the Management of Mixed Arteriovenous Leg Ulcers.

Leg ulceration is a chronic health condition that constitutes a significant disease burden. In this cross-sectional descriptive study, a sample of wound care clinicians were asked to respond to a web-based survey. Based on a review of literature and recommended best practices in the management of mixed arteriovenous (AV) ulcers, a questionnaire was developed to examine the knowledge, attitude, and practice pattern in the management of AV ulcers. A total of 436 clinicians participated in the survey. A number of assessment techniques were perceived to be relevant for the assessment of AV ulcers; medical history and the appearance of ulcers were the most commonly used methods in clinical practice. While over 80% of the participants conceded that compression should be used to promote wound healing, half of them would consider using compression for AV ulcers if ankle brachial index was less than 0.8. Half of the participants considered an ankle brachial index of 0.8 or higher as the optimal cutoff value for safe compression. The majority of respondents disagreed with the perception that caring for people with AV ulcers was unrewarding. However, challenges to promote treatment adherence, address psychosocial concerns, and optimize symptom management are common.

Physicians' knowledge and attitudes in the management of wound infection.

Despite consensus on the assessment and management of wound infection, there exist deficiencies in its recognition and management. A survey study involving 85 physicians and 3 other clinicians from across Canada was completed to determine current knowledge and attitude towards learning about topics relating to wound infection and its management. The results of the survey describe knowledge gaps and interests to develop expertise in the management of wound infection, suggesting a need for education on this subject. Low levels of current knowledge were reported for all biofilm-related topics.

The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice.

PURPOSE: To provide information about product selection for the management of skin tears. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Explain skin tear (ST) risk factors and assessment guidelines.2. Identify best practice treatments for STs, including the appropriate dressings for each ST type. ABSTRACT: To aid healthcare professionals in product selection specific for skin tears, the International Skin Tear Advisory Panel conducted a systematic literature review and 3-phase Delphi consensus with a panel of international reviewers to provide the best available evidence for product selection related to the treatment of skin tears.

The Anti-Inflammatory and Antibacterial Action of Nanocrystalline Silver and Manuka Honey on the Molecular Alternation of Diabetic Foot Ulcer: A Comprehensive Literature Review.

Honey and silver have been used since ancient times for treating wounds. Their widespread clinical application has attracted attention in light of the increasing prevalence of antibiotic-resistant bacteria. While there have been a number of studies exploring the anti-inflammatory and antibacterial effects of manuka honey and nanocrystalline silver, their advantages and limitations with regard to the treatment of chronic wounds remain a subject of debate. The aim of this paper is to examine the evidence on the use of nanocrystalline silver and manuka honey for treating diabetic foot ulcers through a critical and comprehensive review of in vitro studies, animal studies, and in vivo studies. The findings from the in vitro and animal studies suggest that both agents have effective antibacterial actions. Their anti-inflammatory action and related impact on wound healing are unclear. Besides, there is no evidence to suggest that any topical agent is more effective for use in treating diabetic foot ulcer. Overall, high-quality, clinical human studies supported by findings from the molecular science on the use of manuka honey or nanocrystalline silver are lacking. There is a need for rigorously designed human clinical studies on the subject to fill this knowledge gap and guide clinical practice.

Topical Agents and Dressings for Pilonidal Sinus Wound Healing by Secondary Intention: A Scoping Review.

Pilonidal disease (PD) is a chronic and debilitating condition. The overall aim of the scoping review is to map and summarize a wide range of evidence to examine which topical agent or dressing is effective in promoting pilonidal wound healing by secondary intention. Review of this cumulative body of evidence will inform care and guide dressing selection for PD related wounds and delineate future research priorities based on identified knowledge gaps and clinical practice issues. Overall, there is some evidence to suggest that topical applications of hydrogel, silver, honey, zinc, selected foam materials, negative pressure wound therapy, platelet rich plasma, and plant extracts may promote wound healing. Topical treatment using polyhexamethylene biguanide and silver may be beneficial in reducing bacterial burden. Finally, silver, honey, and hydrocolloid dressings may help alleviate wound related pain. However, evidence remains insufficient in light of methodological limitations and biases of the studies.