Wound management in postacute care

Factors Influencing Pressure Ulcer Healing in Adults Over 50: An Exploratory Study

OBJECTIVE

The purpose of this study was to determine which demographic, clinical, and treatment factors influenced chronic pressure ulcer healing, and to identify the implications for pressure ulcer care being delivered in skilled nursing facilities.

DESIGN

A multisite retrospective chart review was conducted using a structured data abstraction form and protocol.

SETTING

Data collection took place in 3 geographically disperse areas of the country, with subjects having received wound care in hospitals, clinics, nursing homes, and home care.

PARTICIPANTS

Subjects whose charts were reviewed were 50 years of age or older, had at least 1 diagnosed chronic pressure ulcer, and had 3 to 6 months of data available for abstraction. Stage I ulcers were excluded from the analysis.

MEASURES

The structured data collection form included demographics, clinical variables, wound characteristics, and outcomes. The variables ulcer size, exudate type and amount, and necrotic tissue type were combined into a single wound severity score.

RESULTS

Bivariate analyses showed that insurance type, secondary diagnoses of cardiovascular disease and pulmonary disease, initial ulcer size and stage, dressing type changes, use of topical antiseptics, type of debridement, category of dressing, use of hydrocolloid or wet-to-dry dressings, antibiotic administration, and appropriateness of selected dressing and management of necrosis were all significantly associated with healing within 6 months. Logistic regression models identified the following as the most significant predictors of healing: Medicaid, secondary diagnosis of cardiovascular disease, dressing type changed, topical antiseptics, antibiotic administration, pressure relief device, lack of exudate management dressing for moderate or large exudate wound, and lack of debridement of wounds with yellow slough, all decreased the odds of healing; use of exudate management dressings on wounds with no documented exudate increased the odds of healing.

CONCLUSION

Pressure ulcer healing rates overall could be improved if clinicians better matched the characteristics of the wound with the decision to debride and the selection of the optimal dressing. Healing within nursing homes might be improved with less use of enzymatic debridement and antibiotics and more frequent application of hydrocolloid dressings.

A controlled, randomized, comparative study of a radiant heat bandage on the healing of stage 3–4 pressure ulcers: A pilot study

OBJECTIVES

Pressure ulcers, like other chronic wounds, fail to proceed through an orderly and timely process to produce anatomical or functional integrity. Treatment of pressure ulcers is directed to improving host factors and providing an optimum wound environment. In addition to providing a moist wound environment, it has been theorized that preventing hypothermia in a wound and maintaining a normothermic state might improve wound healing.

DESIGN/SETTING

Forty-one subjects with a stage 3 or stage 4 truncal pressure ulcer >1.0 cm(2) were recruited from outpatient clinics, long-term care nursing homes, and a rehabilitation center. The experimental group was randomized to a radiant-heat dressing device and the control group was randomized to a hydrocolloid dressing, with or without a calcium alginate filler. Subjects were followed until healed or for 12 weeks.

RESULTS

Eight subjects (57%) in the experimental group had complete healing of their pressure ulcer compared with 7 subjects (44%) with complete healing in the control group (P = .46).

CONCLUSION

Although a 13% difference in healing rate between the two arms of the study was found, this difference was not statistically significant. At almost all points along the healing curve, the proportion not healed was higher in the control arm.

Special issues in plastic and reconstructive surgery

Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.

The role of wound-bed preparation in managing chronic pressure ulcers

The relatively modern concept of wound-bed preparation draws together elements of current practice, including various methods of 'maintenance debridement' and the use of antibiotics and antiseptic agents, to speed up healing of chronic wounds.

Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel

The number of frail, older residents of long-term care facilities (LTCFs) will increase dramatically over the next 30 years. Improving the quality of health care provided in LTCFs is an important national and international priority. Improving the prevention and management of infections in LTCFs is a critical component of efforts to improve quality of care and poses unique challenges. This report summarizes the presentations and discussions of participants in an invitational conference to propose a research agenda for prevention and management of infections in LTCFs. The conference was held in March 2001 in Atlanta, Georgia. The discussants identified key research questions to better understand general issues involving the overall burden of infections in LTCFs, prevention and control interventions, and antimicrobial use and resistance. The participants also discussed research questions involving specific infections, including pneumonia and urinary tract, skin, and soft tissue infections. Recommendations for research were discussed and are presented in summary form in this report. Improving the prevention and management of infections in LTCF residents should be a priority if quality of care in these facilities is to be improved. Many unanswered questions remain in this field, and the research agenda outlined in this report will require resources and focus. The benefit of such efforts to LTCF residents and their caregivers is likely to be substantial.