Bacterial species distribution on the genital skin of hospitalized patients with stroke manifesting incontinence-associated dermatitis: A cross-sectional study.

AIM: To compare the isolated and identified bacterial species colonizing on the genital skin between patients with and without incontinence-associated dermatitis. METHODS: This cross-sectional study included 102 patients with stroke admitted to an acute hospital in Japan. Swabs were collected, and bacterial species found in swabs were isolated and identified using a selective agar medium and simple identification kits. In addition to demographic information, severity of incontinence-associated dermatitis and the total bacterial counts were measured. RESULTS: Incontinence-associated dermatitis was present in 53.9% of the participants. Staphylococcus aureus was found in 50% of the participants with incontinence-associated dermatitis and only 17.9% of those without incontinence-associated dermatitis (P = 0.0029). Bacterial species distribution by erythema and skin erosion, which denote severity of incontinence-associated dermatitis, was different, but not significant; additionally, the total number of bacterial colonies was equivalent. CONCLUSIONS: Bacterial species distribution differed between patients with and without incontinence-associated dermatitis, whereas the total number of bacterial colonies was equivalent. A high detection rate of S. aureus on genital skin sites potentially affects the presence of incontinence-associated dermatitis and its severity. Geriatr Gerontol Int 2023; 23: 537-542.

Selective detection of urease-producing bacteria on the genital skin surface in patients with incontinence-associated dermatitis.

We aimed to investigate the association between the presence of cutaneous urease-producing bacteria and the development of incontinence-associated dermatitis (IAD) using an original urea agar medium as a step toward developing advanced preventive measures. In previous clinical assessments, we developed an original urea agar medium to detect urease-producing bacteria via the medium's colour changes. In a cross-sectional study, specimens were collected via the swabbing technique at genital skin sites in 52 stroke patients hospitalised in a university hospital. The primary objective was to compare the presence of urease-producing bacteria between the IAD and no-IAD groups. Determining the bacterial count was the secondary objective. The prevalence of IAD was 48%. A significantly higher detection rate of urease-producing bacteria was observed in the IAD group than in the no-IAD group (P = .002) despite the total number of bacteria being equivalent between them. In conclusion, we discovered that there was a significant association between the presence of urease-producing bacteria and IAD development in hospitalised stroke patients.

Nursing management for temporary lodging facilities in Japan in the early stages of the COVID-19 pandemic: A multiple-case study.

AIM: Temporary lodging facilities which were non-medical facilities were established to secure beds for severely and moderately ill patients with COVID-19, as well as for isolation, non-contact observation, and care of mildly ill and asymptomatic patients in Japan. This study aims to understand nursing management practices adopted in these facilities by examining cases of their establishment and operation. METHODS: A multiple-case study design was used. Interviews for qualitative data collection were conducted from August to October 2020. After analyzing the nursing management practices in four temporary lodging facilities, common points were collated and integrated. RESULTS: For the establishment and operation of temporary lodging facilities, a three-layer structure based on disaster management methods was adopted: headquarters at the helm as overseers, field supervisors in the middle, and frontline nursing staff at the base. The structure had clear roles, facilitated information exchange, and provided efficient and effective nursing care. Field supervisors mainly provided psychological and clinical support for staff and served as information and interprofessional hubs. CONCLUSION: It is recommended that temporary lodging facilities should be organized based on principles of the division of labor. The workforce should comprise nursing staff, and experienced nursing professionals should be recruited to the higher echelons.

Key strategies for managing nursing care under the COVID-19 pandemic: A multiple-case study of nursing directors.

AIM: We aim to identify measures implemented by hospital nursing directors early in the COVID-19 pandemic and enabling factors. BACKGROUND: Managerial factors affect nurses' physical and mental health and willingness to work, especially early in a pandemic. METHOD: We used multiple-case study of 15 hospitals, comparing management approaches by interviewing 28 nursing directors and their assistants from August to December 2020. RESULTS: Hospitals that accepted COVID-19 patients and hospitals that unexpectedly experienced clusters underwent a nursing provision system organization phase, followed by an adjustment phase to maintain nursing organization function. Two factors aided measure implementation: an emergency system and staff protection policies. CONCLUSION: Early epidemic management strategies apply across contexts. The hospital's basic attitude is key to effective implementation of the strategies. IMPLICATIONS FOR NURSING MANAGEMENT: The results suggest that hospitals, nursing directors and nurses can each prepare for future emerging infectious disease epidemics.

Perceived impact of nurse turnover on the organization: A Delphi study on managers of nursing.

AIMS: The study aimed to identify the aspects and items of nurse turnover impact on organizations as perceived by nursing management. BACKGROUND: Turnover rate does not capture the extent to which an organization is affected by turnover. Another indicator is required to assess the control status of turnover impact. METHODS: A Delphi study was conducted in 2021, where 2670 managers of nursing at 712 hospitals were asked to complete the survey three times. Factor analysis was conducted on these items for which a consensus was reached. RESULTS: Overall, 232 managers who responded multiple times, including the third survey, were included in the analysis. Consensus was reached for 36 items affected by turnover and considered important for nursing management. Using exploratory factor analysis, the following six factors were extracted: quality of nursing care, physical and mental health of nursing staff, workload and working conditions of nursing staff, relationships among nursing staff members, sense of responsibility among nursing staff, and cost and benefit of hiring replacement personnel. CONCLUSIONS: Six factors consisting of 36 items were extracted that can be used to assess the impact of nurse turnover. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can assess the status of the organization more appropriately by understanding the factors that impact nurse turnover in vaious facilitites and look at strategies to overcome the impact on nurse staffing.

Work-related communication mediates the relationship between perceived diversity climate and psychological empowerment among part-time nurses: A cross-sectional study.

AIM: This study investigates which work-related communication mediates the relationship between diversity climate and psychological empowerment among part-time nurses. BACKGROUND: Part-time nurses' high psychological empowerment is desirable because it may lead to high quality nursing practice. METHODS: Anonymous self-report questionnaires or web-based surveys were used to measure diversity climate (Climate for Inclusion Scale), psychological empowerment (Japanese version of the Psychological Empowerment Scale) and work-related communication (scale developed in this study). The respondents were part-time nurses from departments with shift work in six Japanese hospitals having over 200 beds. The surveys were conducted from September to October 2020. Multiple regression analyses and a significance test of indirect effects were then conducted. RESULTS: Among the work-related communication components, 'expressing thoughts about their work' fully mediated the relationship between diversity climate and psychological empowerment. CONCLUSIONS: It is important for part-time nurses to be actively 'expressing thoughts about their work' to enhance their psychological empowerment. Positive diversity climate is also important because it allows part-time nurses to express their thoughts regarding work. IMPLICATIONS FOR NURSING MANAGEMENT: Managers can enhance part-time nurses' psychological empowerment by encouraging them to express their work-related opinions based on the diversity climate.

Association Between Access to Specialists and History of Cellulitis Among Patients with Lymphedema: Secondary Analysis Using the National LIMPRINT Database.

Background: Cellulitis is frequently encountered in patients with lymphedema despite existing prevention protocols. To resolve this issue, social aspects surrounding patients, such as communication with patients and professionals, are necessary to consider new approaches. This study aimed to clarify the association between the history of cellulitis in patients with lymphedema and access to specialists after adjustment for relevant confounding factors. Methods and Results: This study was a secondary analysis of the Lymphoedema IMpact and PRevalence-INTernational (LIMPRINT) study using a national Japanese database of adult lymphedema compiled between 2014 and 2015 (n = 113). Descriptive data were collected for patient characteristics. Multivariate logistic regression analysis was conducted to explore possible risk factors for patients having experienced cellulitis. The duration of edema ranged from <6 months (16.2%) to 10 years or longer (25.2%), with varying severity. History of cellulitis was observed in 31.9% of patients. The prevalent treatment techniques within the context of complex decongestive therapy included skin care advice (52.2%), compression garments (55.8%), exercise advice (41.6%), multilayer bandages (38.1%), cellulitis advice (49.6%), and massage (61.1%). Overall, 57.1% of patients had access to lymphedema specialists. Longer duration of lymphedema (adjusted odds ratio [AOR] = 4.10, p = 0.005) and access to lymphedema specialists (AOR = 0.28, p = 0.009) were significantly associated with a history of cellulitis. Conclusions: A history of cellulitis in patients with lymphedema is associated with limited access to specialists. To support self-care in this patient population, reasonable consideration systems, including telehealth, should be developed to facilitate communication between specialists and patients and decrease the occurrence of cellulitis in lymphedema.

Local wound management factors related to biofilm reduction in the pressure ulcer: A prospective observational study.

AIMS: Critical colonization in pressure ulcers delays healing and has been studied. However, local wound management includes no clear strategy for preventing the development of biofilms. Therefore, this multicenter, prospective, observational study was conducted to examine the effect of local management on the biofilm area of pressure ulcers with critical colonization. METHODS: Participants were 34 patients with a pressure ulcer deeper than the dermis and in a state of critical colonization. The primary outcome was the change over a week in the proportion of the biofilm area in relation to that of the pressure ulcer area. We investigated the relationship between primary outcome and local wound management. The wound-blotting method was used for determining the biofilm area. To calculate the change in the biofilm area, baseline proportion was subtracted from proportion 1 week later. RESULTS: Six types of topical treatment were used in three facilities. The proportion of the biofilm area at 1 week follow-up was significantly smaller with iodine ointment than that without iodine ointment (p = .02). The standardized partial regression coefficient of iodine ointment adjusted by the type of medical facility was -0.26 (p = .003). CONCLUSION: This study revealed that the use of iodine ointment reduced the proportion of the biofilm area in the pressure ulcer surface. To manage pressure ulcers in a state of critical colonization, these results suggest that local management include the use of iodine ointment.

The reliability and validity of color indicators using digital image analysis of peristomal skin photographs: results of a preliminary prospective clinical study.

Accurate assessment is necessary to evaluate peristomal skin condition, but objective methods are lacking. The purpose of this prospective, repeated-measures study was to evaluate the reliability and validity of color indicators using digital image analysis of peristomal skin photographs. The 6-month study was conducted among 21 patients (mean age 65.1 years old, 15 men) with ostomies (14 colostomies, six ileostomies, and one urostomy) at four outpatient clinics. Photographs taken by nurses of the peristomal area using point-and-shoot cameras were processed using digital image analysis, which involved color calibration, image processing, and indicator calculation. An erythema index (EI), melanin index (MI), and hypopigmentation index were created to represent increased degrees of red, black, and white color, respectively, and their average values in the peristomal region of an image were calculated relative to values for intact skin. Reproducibility was evaluated using the interclass correlation coefficient (ICC). ICCs of color indicators for intact skin were >0.7 between baseline and the end of follow-up for the 16 participants with two or more clinic visits. Differences in these indices between peristomal and intact regions were evaluated using a linear mixed model. The EI and MI of peristomal skin were significantly higher than those of intact skin (n=42, P<0.001). All color indicators in adjacent regions and areas where adhesive was applied were associated with the discoloration severity score and visual analogue pain score (all P<0.05). This objective and simple method had adequate reproducibility and criterion-related validity and may be useful for peristomal skin assessment. Further research is warranted.

Combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury.

Early detection and intervention of deep tissue injury are important to lead good outcome. Although the efficiency of ultrasonographic assessment of deep tissue injury has been reported previously, it requires a certain level of skill for accurate assessment. In this study, we present an investigation of the combination of thermographic and ultrasonographic assessments for early detection of deep tissue injury. We retrospectively reviewed 28 early-stage pressure ulcers (21 patients) presenting at the University of Tokyo Hospital between April 2009 and February 2010, surveying the associated thermographic and ultrasonographic findings. The wound temperature patterns were divided into low, even and high compared with the surrounding skin. Ultrasonographic findings were classified into unclear layer structure, hypoechoic lesion, discontinuous fascia and heterogeneous hypoechoic area. All 13 ulcers that were associated with low temperature showed good outcome; three ulcers had even temperatures and 12 ulcers showed high temperature on thermographic assessment. The two deep tissue injuries were rated high on thermographic assessment and showed heterogeneous hypoechoic area findings on ultrasonographic assessment. No non-deep tissue injury lesion was associated with these two findings simultaneously. The combination of thermographic and ultrasonographic assessments is expected to increase the accuracy of the early detection of deep tissue injuries.

Wound blotting: a convenient biochemical assessment tool for protein components in exudate of chronic wounds.

Because wound exudate includes secreted proteins that affect wound healing, its biochemical analysis is useful for objective assessment of chronic wounds. Wound blotting allows for collection of fresh exudate by attaching a nitrocellulose membrane onto the wound surface. To determine its applicability for several analysis methods and its executability in clinical wound assessment, this study comprised an animal experiment and clinical case reports. In the animal experiment, full-thickness wounds were created on the dorsal skin of mice, and exudate samples were collected daily by a conventional method and by wound blotting. Extremely small but adequate volumes of exudate were collected by wound blotting for subsequent analysis in the animal experiments. Immunostaining showed the concentration and distribution of tumor necrosis factor (TNF) α. The activity of alkaline phosphatase was visualized by reaction with chemiluminescent substrate. The TNF distribution analysis indicated three different patterns: wound edge distribution, wound bed distribution, and a mostly negative pattern in both the animal and clinical studies, suggesting association between the TNF distribution pattern and wound healing. Our results indicate that wound blotting is a convenient method for biochemical analysis of exudate and a candidate tool with which to predict the healing/deterioration of chronic ulcers.

Predictive validity of granulation tissue color measured by digital image analysis for deep pressure ulcer healing: a multicenter prospective cohort study.

This multicenter prospective cohort study examined the predictive validity of granulation tissue color evaluated by digital image analysis for deep pressure ulcer healing. Ninety-one patients with deep pressure ulcers were followed for 3 weeks. From a wound photograph taken at baseline, an image representing the granulation red index (GRI) was processed in which a redder color represented higher values. We calculated the average GRI over granulation tissue and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) and wound surface (%wound red index 80). In the receiver operating characteristics curve analysis, most GRI parameters had adequate discriminative values for both improvement of the DESIGN-R total score and wound closure. Ulcers were categorized by the obtained cutoff points of the average GRI (≤80, >80), %GRI80 (≤55, >55-80, >80%), and %wound red index 80 (≤25, >25-50, >50%). In the linear mixed model, higher classes for all GRI parameters showed significantly greater relative improvement in overall wound severity during the 3 weeks after adjustment for patient characteristics and wound locations. Assessment of granulation tissue color by digital image analysis will be useful as an objective monitoring tool for granulation tissue quality or surrogate outcomes of pressure ulcer healing.

Concurrent validation and reliability of digital image analysis of granulation tissue color for clinical pressure ulcers.

Granulation tissue color is one indicator for pressure ulcer (PU) assessment. However, it entails a subjective evaluation only, and quantitative methods have not been established. We developed color indicators from digital image analysis and investigated their concurrent validity and reliability for clinical PUs. A cross-sectional study was conducted on 47 patients with 55 full-thickness PUs. After color calibration, a wound photograph was converted into three images representing red color: erythema index (EI), modified erythema index with additional color calibration (granulation red index [GRI]), and , which represents the artificially created red-green axis of L(*) a(*) b(*) color space. The mean intensity of the granulation tissue region and the percentage of pixels exceeding the optimal cutoff intensity (% intensity) were calculated. Mean GRI (ρ=0.39, p=0.007) and (ρ=0.55, p<0.001), as well as their % intensity indicators, showed positive correlations with a(*) measured by tristimulus colorimeter, but erythema index did not. They were correlated with hydroxyproline concentration in wound fluid, healthy granulation tissue area, and blood hemoglobin level. Intra- and interrater reliability of the indicator calculation using both GRI and had an intraclass correlation coefficient >0.9. GRI and from digital image analysis can quantitatively evaluate granulation tissue color of clinical PUs.

Combination of Ultrasonographic and Thermographic Assessments for Predicting Partial-thickness Pressure Ulcer Healing .

UNLABELLED: The ability to predict the prognosis of a pressure ulcer is re- quired to establish appropriate management in the early phase. The present study reports the usefulness of a combined assessment tech- nique using ultrasonography and thermography for predicting delayed wound healing. METHODS: This retrospective cohort study included 37 patients with Stage I or II pressure ulcers. The patients were followed up for at least 3 weeks. The ultrasonographic and thermographic as- sessments were conducted at the initial multidisciplinary team round. The presence of four ultrasonographic features (unclear layered struc- ture, hypoechoic lesion, discontinuous fascia, and heterogeneous hy- poechoic area) and one thermographic feature (increased temperature) were determined from within the wound bed. Wound healing was re- assessed after 2 weeks and the rate of area reduction was calculated to determine whether the pressure ulcer was healing properly. A mul- tivariate logistic analysis was used to assess the predictive values of the possible assessment features. RESULTS: A comprehensive review of the ultrasonographic and thermographic assessments of the pressure ulcers found that the combination of unclear layered structure and increased temperature was beneficial for predicting wound healing. When a pressure ulcer presented with an unclear layered structure and increased temperature in the wound bed, the risk of delayed wound healing or wound deterioration was 6.85 times higher compared with a pressure ulcer that did not have these manifestations. CONCLUSION: The combination of ultrasonographic and thermographic assessments facilitates precise prediction of pressure ulcer outcomes.

Do nutritional markers in wound fluid reflect pressure ulcer status?

Evaluation of wound fluid characteristics for pressure ulcer (PU) assessment in clinical settings remains subjective, requiring considerable expertise. This cross-sectional study focused on nutritional markers in wound fluid as possible objective tools and investigated whether they reflect the PU status according to the healing phase, infection, and granulation, especially after adjusting for serum values. Twenty-eight patients with 32 full-thickness PUs were studied. The concentration of albumin, total protein, glucose, and zinc in wound fluid were measured. For PU status, the healing phases and infection were evaluated by clinical signs, and the degree of granulation tissue formation was determined as the hydroxyproline concentration. The wound fluid/serum ratio for albumin was significantly lower during the inflammatory phase than during the proliferative phase (p=0.020). Infected wound fluid contained less glucose (0.3-1.0 mmol/L) than noninfected ones did (5.0-7.6 mmol/L) in an intraindividual comparison of three cases. The wound fluid/serum ratio for glucose was negatively correlated with hydroxyproline level in the proliferative phase (rho=-0.73, p=0.007), while zinc level in wound fluid showed a positive correlation (rho=0.61, p=0.028). Our results suggest that these traditional nutritional markers in wound fluid, especially wound fluid/serum ratio may be useful to evaluate local PU status.

Estimation of protein loss from wound fluid in older patients with severe pressure ulcers.

OBJECTIVE: Protein loss from wound fluid is usually recognized as one of the factors contributing to the deterioration of the nutritional status in older patients with severe pressure ulcers. We quantified the protein loss owing to pressure ulcers and investigated associations with wound-related factors and nutritional status. METHODS: This cross-sectional study included 25 patients (>or=60 y) from 10 institutions, with full-thickness pressure ulcers. Wound fluid was collected once after accumulating beneath a film dressing. The amount of protein loss per day was estimated by the volume of wound fluid per hour and the total protein concentration in the wound fluid. Wound evaluations and nutritional assessments were performed. Correlations between variables were obtained using Spearman's rank correlation. RESULTS: The median age of the patients was 79 y (range 61-100), and median body mass index was 19.6 kg/m(2) (12.2-24.9). The median amount of protein loss was 0.2g/d (0.04-2.1), which corresponded to 0.01 g x kg(-1) x d(-1) (<0.01-0.04) and 0.6% (0.1-13.8) of protein intake. Four wounds characterized as infected or surgically debrided lost 1.5-2.1g of protein per day, which was substantially higher than other wounds lost. Protein loss was correlated with wound severity including area, depth, the wound severity score, and infectious markers (all Ps<0.05), but not with body mass index or arm muscle circumference (P>0.05). CONCLUSION: The amount of protein loss could be small and thus may not be related directly to nutritional status, although it increased as the wound became more severe.