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.

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.

Wound Bed Preparation 2021.

GENERAL PURPOSE: To present the 2021 update of the Wound Bed Preparation paradigm. 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. Apply wound assessment strategies. 2. Identify patient concerns about wound care. 3. Select management options for healable, nonhealable, and maintenance wounds.

Wound Bed Preparation is a paradigm to optimize chronic wound treatment. This holistic approach examines the treatment of the cause and patient-centered concerns to determine if a wound is healable, a maintenance wound, or nonhealable (palliative). For healable wounds (with adequate blood supply and a cause that can be corrected), moisture balance is indicated along with active debridement and control of local infection or abnormal inflammation. In maintenance and nonhealable wounds, the emphasis changes to patient comfort, relieving pain, controlling odor, preventing infection by decreasing bacteria on the wound surface, conservative debridement of slough, and moisture management including exudate control. In this fourth revision, the authors have reformulated the model into 10 statements. This article will focus on the literature in the last 5 years or new interpretations of older literature. This process is designed to facilitate knowledge translation in the clinical setting and improve patient outcomes at a lower cost to the healthcare system.

Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway.

GENERAL PURPOSE: To synthesize the evidence regarding nonhealable and maintenance wound management and propose an interprofessional referral pathway for wound management. 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: After participating in this continuing professional development activity, the participant will apply knowledge gained to:1. Identify the ideas from the authors' systematic review that could prove useful in understanding nonhealable and maintenance wound management.2. Select evidence-based management strategies for nonhealable and maintenance wound management. ABSTRACT: OBJECTIVEThis systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed. DATA SOURCES: An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: ConsumerEdition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors. STUDY SELECTION: Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected. DATA EXTRACTION: Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention. DATA SYNTHESIS: Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes. CONCLUSIONS: Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.

This systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed. An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: Consumer Edition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors. Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected. Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention. Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes. Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.

Patient-Centered Health Education Intervention to Empower Preventive Diabetic Foot Self-care.

BACKGROUND: Diabetes impairs the body's ability to produce or respond to the hormone insulin resulting in abnormal metabolism of carbohydrates and elevated glucose levels in the body. Because of these factors, diabetes can cause several complications that include heart disease, stroke, hypertension, eye complications, kidney disease, skin complications, vascular disease, nerve damage, and foot problems. Diabetes education allows patients to explore effective interventions into living their life with diabetes and incorporate the necessary changes to improve their lifestyle. OBJECTIVE: To educate patients diagnosed with diabetes or followed up for diabetes management by other departments with regard to their own responsibility in maintaining preventive foot self-care. METHODS: Ten patients completed a validated educational foot care knowledge assessment pretest to determine their existing knowledge about their own foot care after a thorough foot assessment. Preventive diabetic foot self-care education was conducted through a lecture, visual aids, and a return demonstration. Patients then took a posttest questionnaire with the same content as the pretest to determine their uptake of the educational content. RESULTS: Correct toenail cutting was the most identified educational need. It was a limitation in the pretest (30%), and it remained the lowest-scoring item on the posttest (70%). Walking barefoot was thought to be safe by 60% of participants pretest, but with remedial education, all participants identified this as a dangerous activity posttest. Participants also understood the high importance of having corns and calluses looked after by a health professional. CONCLUSIONS: Effective communication with patients by healthcare providers who can mold educational content to identified patient needs by teaching much needed skills is a key driver in rendering safe, quality healthcare education interventions.

Preventing Facial Pressure Injury for Health Care Providers Adhering to COVID-19 Personal Protective Equipment Requirements.

OBJECTIVE: To determine if a repurposed silicone-based dressing used underneath an N95 mask is a safe and beneficial option for facial skin injury prevention without compromising the mask's seal. METHODS: Since February 21, 2020, staff in high-risk areas such as the ED and ICU of King Hamad University Hospital have worn N95 masks when performing aerosol-generating procedures to protect against the novel coronavirus 2019. At that time, without education enablers or resources that could be directly translated into practice, the hospital's Pressure Injury Prevention Committee explored, created, and tested a stepwise process to protect the skin under these masks while ensuring that it did not interfere with the effectiveness of the N95 mask seal. RESULTS: Skin protection was achieved by repurposing a readily available silicone border dressing cut into strips. This was tested on 10 volunteer staff members of various skin types and both sexes. Oxygen saturation values taken before and after the 4-hour wear test confirmed that well-fitted facial protection did not compromise the mask seal, but rather improved it. Staff also self-reported increased comfort with less friction. An educational enabler to prevent MDRPI from N95 mask wear was an important additional resource for the staff. CONCLUSIONS: This creative and novel stepwise process of developing a safe skin protection method enabling staff to apply a repurposed silicone border dressing beneath an N95 mask was largely effective and aided by the creation of the enabler.

25-Hydroxyvitamin D Deficiency: Impacting Deep-Wound Infection and Poor Healing Outcomes in Patients With Diabetes.

BACKGROUND: The Kingdom of Bahrain has a high incidence of diabetes and associated foot complications. Simultaneously, low 25-hydroxyvitamin D (25[OH]D) levels are common in this population and may be associated with the traditional clothing used in desert climates. METHODS: This investigation compared 25(OH)D levels and glycemic control with quantifiable wound healing parameters in a prospective, analytic, nonexperimental, cross-sectional pilot study. Consecutive consenting adult patients (N = 80) who presented to the regional wound care unit in January 2016 with either an existing or new wound were included. Collected data included three-dimensional wound photography, NERDS and STONEES criteria, and an X-ray with a positive probe-to-bone test. Blood values for 25(OH)D and hemoglobin A1c (HbA1c) were collected simultaneously. RESULTS: Diabetes mellitus (types 1 and 2) was present in 90% of the sample patients. No patient had sufficient 25(OH)D levels; 15% had insufficient levels (30-50 ng/mL), and deficiency (levels <#20 ng/mL) was found in 85% of the sample. Males were slightly less affected by 25(OH)D deficiency compared with females (82.4% vs 91.3%). Poor glycemic control (HbA1c levels >#6.8%) was found in 69.4% (n = 50) of the persons with diabetes included in the sample. Those with both diabetes mellitus and a 25(OH)D deficiency (76.3%; n = 61) were more likely to demonstrate healing difficulty (40.9%; n = 25) or present with a stalled or deteriorating wound (44.2%, n = 27). A 3° F or higher periwound surface temperature elevation over a mirror image site was present in 82.5% of all wounds. Exposed bone in the ulcer base was found in 50% of the cases. For persons with diabetes, general linear modeling statistical analysis (adjusted R value = 47.9%) linked poor wound healing with three studied variables: 25(OH)D deficiency, poor glycemic control, and an exposed bone in the wound bed. CONCLUSIONS: Vitamin D may be an overlooked factor in the pathophysiology of diabetic foot ulcer development and subsequent delay in wound healing outcomes. The authors recommend adding 25(OH)D deficiency to the list of multifactorial aggravating factors providers should consider correcting in this subgroup of patients.

Survey Results from the Gulf Region: NPUAP Changes in Pressure Injury Terminology and Definitions.

Pressure injuries/ulcers are a global health issue, and there is a need for clinicians from many countries and continents to express their opinions on the terminology change (pressure ulcer to injury) and revised staging definitions. A convenience, opinion survey sample of clinicians from the Western Asia Gulf Region enrolled in a yearlong wound care course participated by expressing their opinion about these changes. Results reveal support for the pressure injury terminology and the revised staging definitions.

Assessing Pressure Injury Knowledge Using the Pieper-Zulkowski Pressure Ulcer Knowledge Test.

OBJECTIVE: To determine the pressure injury knowledge of health professionals before and after providing an interactive, educational intervention. DESIGN AND SETTING: The research design was a quasi-experimental study using a nonrandomized pretest/posttest methodology in Manila, Philippines. PATIENTS AND INTERVENTION: The population for this study was healthcare professionals who participated in a 2-day Basic WoundPedia course. There were 57 participants on day 1 and 55 participants on day 2. The Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT, version 2), a standardized, validated instrument with 72 items, was used to measure 3 domains: prevention (28 items), staging (20 items), and wounds (24 items). The test was used to determine the baseline pressure injury knowledge of the students on day 1 before the course began and on day 2 after related content was completed. The intent of this approach was to document that knowledge deficits were met, especially for future courses. MAIN RESULTS: There was a statistically significant increase in pressure injury knowledge scores after healthcare professionals received an interactive, educational intervention. CONCLUSIONS: Measuring knowledge before and after educational intervention should be considered to determine whether knowledge deficits are corrected. This methodology reinforced the adult learning theory and to help participants realize their own knowledge deficits. The PZ-PUKT may prove a valuable nonthreatening instrument for adult learners to self-identify, self-learn, and self-correct knowledge according to the best new evidence as it becomes available. These findings documented that this interactive, educational intervention did improve the percentage of correct pressure injury knowledge concepts for this group in all 3 subscales. This study also added support for the newly revised PZ-PUKT.