Ingredient-based wound dressing classification: a paradigm that is passe and in need of replacement

Wound dressings are classified according to their ingredients, but in many cases dressings within the same group have different recommended uses and even ingredients. Should future classifications be based on dressing functions?

Documentation with MDS Section M: Skin Condition

The Minimum Data Set is designed to be the assessment instrument used in all long-term-care facilities receiving federal funds for Medicare and Medicaid. However, Section M: Skin Condition is one of the most challenging sections to complete when trying to match the Minimum Data Set documentation with the true clinical picture. If wounds are not adequately assessed and documented, outcomes of care cannot be evaluated, and treatment and prevention plans will be inadequate. This may result in less than optimal outcomes and possible lawsuits for inadequate care against both the caregiver and facility. The purpose of this article is to provide examples of medical record documentation necessary to support the Minimum Data Set assessment.

Using wound care algorithms: a content validation study

PURPOSE

Valid and reliable heuristic devices facilitating optimal wound care are lacking. The objectives of this study were to establish content validation data for a set of wound care algorithms, to identify their associated strengths and weaknesses, and to gain insight into the wound care decision-making process.

METHODS

Forty-four registered nurse wound care experts were surveyed and interviewed at national and regional educational meetings. Using a cross-sectional study design and an 83-item, 4-point Likert-type scale, this purposive sample was asked to quantify the degree of validity of the algorithms' decisions and components. Participants' comments were tape-recorded, transcribed, and themes were derived.

RESULTS

On a scale of 1 to 4, the mean score of the entire instrument was 3.47 (SD +/- 0.87), the instrument's Content Validity Index was 0.86, and the individual Content Validity Index of 34 of 44 participants was > 0.8. Item scores were lower for those related to packing deep wounds (P < .001). No other significant differences were observed. Qualitative data analysis revealed themes of difficulty associated with wound assessment and care issues, that is, the absence of valid and reliable definitions.

CONCLUSION

The wound care algorithms studied proved valid. However, the lack of valid and reliable wound assessment and care definitions hinders optimal use of these instruments. Further research documenting their clinical use is warranted. Research-based practice recommendations should direct the development of future valid and reliable algorithms designed to help nurses provide optimal wound care.

Clinical practice guidelines: moving into the 21st century

Clinical practice guidelines affect every aspect of healthcare. Practitioners, third-party payors, regulatory bodies, governments, and accrediting agencies increasingly use these guidelines, which are developed by a wide variety of organizations. The majority of guidelines are based on consensus and a nonsystematic literature review, but some, including those developed by the Agency for Health Care Policy and Research, are evidence based. Both types of guidelines have distinct advantages and limitations. Consensus-based guidelines are less time consuming to develop but may lack crucial information and result in a wide variety of outcomes; whereas, the type of evidence used to develop strength-of-evidence ratings for evidence-based guidelines may result in ambiguous recommendations and cause ethical concerns. Outcomes research on the use of guidelines and issues related to their timeliness need to be addressed. Studies that include a wide variety of outcome indicators and care variables and contributions of clinicians are needed to develop practice guidelines that are clinically useful and improve patient care.

Pressure ulcer patient and wound assessment: an AHCPR clinical practice guideline update

The Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines on the treatment of pressure ulcers are based on the literature published before 1994. For the patient and wound assessment recommendations, a review of the literature from 1993 to 1998 was conducted in an effort to update this section of the guideline. In addition, the strength-of-evidence rating system used was critiqued for its narrow definitions, particularly as it pertains to recommendations related to assessment practices. Studies to determine the prospective validity of the entire guideline, as well as further research to assess the validity of individual recommendations, is needed.

The traditions and terminology of wound dressings: food for thought

During the past 40 years, health care professionals have witnessed an evolution of wound care traditions and terminology and an explosion in the number of wound care products and the amount of information. Unfortunately, these developments have not resulted in optimal wound care for all patients. Appropriate dressing selection and communication are hampered by a lack of clinically valid definitions, as well as ambiguous indications, contraindications, and instructions for their use. One method of setting the stage for a more therapeutic future would be to classify dressings based on their functions rather than the ingredients they contain.

Improved coordination: the wound care specialist

Optimal, cost-effective patient care requires the integration of research findings into practice and a continuing assessment of outcomes attained, which cannot be achieved unless care is continuous and multidisciplinary. Well-defined requirements for the education of an advanced practice nurse results in quality and effective wound-care delivery in a cost-effective fashion. The concerns of business and health must be blended to achieve optimal patient care.

Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital

To assess the prevalence, documentation and care of pressure ulcers, and the effect of teaching and prevention strategies in a 750-bed university hospital, one-day studies were conducted in 1993, 1995, and 1997. Data gathered was used to evaluate areas in need of improvement and find cost-effective ways to reduce the prevalence of pressure ulcers. The overall prevalence of ulcers decreased from 18 percent in 1993 to 10 percent in 1995 and 1997. The prevalence of nosocomial ulcers decreased from 14 percent in 1993 to 8 percent in 1995 and 6 percent in 1997. The number of nutritional consults increased from 54 percent in 1993 to 67 percent in 1997, and more than half of all patients tested had serum albumin levels < 3.5 mg/dL. Skin assessments upon admission were completed in the majority of patients. While ulcer documentation was less than adequate for the majority of patients in 1993 and 1997, care measures, e.g., placement of patients on specialty beds or mattresses and use of dressings that provide a moist environment, improved considerably. The results of this study indicate that system-wide educational efforts aimed at all levels of patient care providers, and multi-specialty prevention and care efforts can reduce the prevalence of pressure ulcers.

Assessing the risk of foot ulcers

Home care nurses are in an ideal position to screen clients and assess their risk of developing foot-related problems, including ulcers. An increased awareness of the potential serious consequences of foot ulcers together with agency assessment and practice guidelines, will help nurses prevent foot-related problems.

Quality wound care equals cost-effective wound care: a clinical model

The cost of wound care frequently is defined as the cost of materials and labor, ignoring the effect of both variables on outcome. As a result, money-saving measures actually may increase cost while reducing the quality of care. Definitions and tools to enable professionals to understand, evaluate, and compare the cost-effectiveness of wound care practices and treatment modalities are given.

Issues in chronic wound care: where do we go from here?

Understanding of the healing process and factors that may affect it, has increased dramatically during recent years. Clinical application of this knowledge has improved care for many patients, and helped focus attention on information deficits. To better meet patient needs and increase awareness of the value of prevention, wound care clinicians and researchers are encouraged to include Quality of Life outcomes in their goals of chronic wound care. In the absence of the results of reliability, validity and feasibility studies of existing chronic wound care guidelines, clinicians need to be aware of their potential usefulness and limitations. When reviewing wound care costs or conducting studies, it is important to define cost-effectiveness as a function of outcomes and all relevant costs. Because chronic wounds occur in every care environment, these issues require the attention of all healthcare professionals, educators, payors and patients. Wound care professionals are encouraged to disseminate existing knowledge to all providers and recipients of care.

The fundamentals of wound assessment

Although many questions related to the process of wound assessment remain unanswered, clinicians agree on one issue: it is better to regularly assess using the same, possibly less-than-perfect tool, than to not assess at all. This article discusses the fundamentals of wound assessment, beginning with defining "assessment." The rationale for wound assessment is based on the goal of care and patient care plan. Frequency depends on the rationale for a particular patient and may, therefore, change over time. Assessing the wound involves a number of steps, beginning with choosing reliable and valid wound assessment methods, which often include: measuring wound area/size and depth, assessing the wound edges, aspect of the wound bed and surrounding skin, as well as the amount and type of exudate and odor. Consistent documentation of all findings is crucial. Wound assessments provide the foundation for the plan of care and are the only way to determine its effectiveness.

Using wound debridement to help achieve the goals of care

The removal of devitalized tissue, particulate matter, or foreign materials from a wound, debridement, is often the first goal of wound care. Debridement can be accomplished surgically (instrument/sharp), chemically, mechanically or by means of autolysis. Each procedure has distinct advantages, disadvantages, indications for use and risks, and a combination of methods will often expedite the process while limiting the chance of complications. Depending on the method used as well as a variety of local and systemic factors, chronic wound debridement can take anywhere from a few days to more than a month. Even though wound debridement is often discussed separately, particularly when managing patients with chronic wounds, it should not be viewed in isolation. Rather, it is one aspect of total patient care. Measures to facilitate the healing process in general should be employed at all times, because debridement and wound healing can occur simultaneously.

Standardizing performance-based criteria for support surfaces

Due to the sparsity of prospective, controlled, clinical studies on the efficacy of and the lack of standardized information about support surfaces, current literature does not clearly define how these surfaces address patient needs. Standardization would help healthcare professionals make better informed decisions about the use of support surfaces. Standardization would also help researchers design and implement controlled, clinical studies by defining characteristics of surface evaluation, making it possible to replicate research activities. The first step toward standardization is to develop a performance-based set of criteria for classifying these surfaces. With respect to the three purposes identified: comfort, postural control and pressure management, only parameters that can be measured noninvasively, have been considered. The nine parameters are life expectancy of the surface, skin moisture control, skin temperature control, redistribution of pressure, product service requirements, fail safety, infection, flammability, and patient/product friction. Specific guidelines for each of these nine parameters are discussed in depth. With testing and evaluation of support surfaces standardized, clinicians will be able to choose a surface to meet the needs of patients the same way they make other treatment decisions: based on outcomes and the results of controlled, clinical studies.

Predictors of time to healing deep pressure ulcers

Time to healing analysis methods (Kaplan-Meier time until healing curves) were used to compare time to healing deep pressure ulcers as a function of patient and wound characteristics at baseline and after two weeks of treatment. Time to healing was significantly reduced in patients who had a good nutritional status. Patients who were alert and coherent were also found to heal more expediently; however, mental status was not independently predictive of time to healing in the multivariable model. Larger wounds took longer to heal (median 20 days) than smaller wounds, but the difference was not statistically significant. After two weeks of treatment, ulcers in patients who were 60 to 70 years old, who had a good nutritional status at baseline and whose ulcers reduced at least 39 percent in size after two weeks, were found to heal much more expediently. Cox regression models showed that these factors were independently predictive of time until healing (Likelihood ratio statistic on 5 DF = 26.485, p < 0.001). Clinical assessments, both at baseline and regular intervals thereafter, may predict treatment outcome of full-thickness pressure ulcers.

Clinical study: peristomal skin irritation in colostomy patients

A prospective, controlled, clinical study was conducted to evaluate the effect of skin barriers and adhesives on the incidence of peristomal skin irritation. Colostomy patients eligible to participate were randomly assigned one of two sets of 10 one-piece pouching systems. At mid-study, after using the first 10 pouches, patients were allocated 10 pouches from the alternate pouching system. Each pouching system was worn for a maximum of 24 hours. One-hundred twelve patients were enrolled in the study. At baseline, 8 percent of patients had some erythema. At the end of the study period, 26 percent of patients exhibited signs of skin irritation. Patients were significantly more likely to develop skin irritation following use of the Karaya-based barrier than following use of the pectin-based barrier product (Wilcoxon Rank Sum Test, p < 0.01). Similarly, the type of tape used to secure the pouching system significantly influenced the incidence of skin irritation. Analysis of the change in skin condition as it relates to all evaluated variables; i.e. pouching system, stoma shape, stoma size, stoma length and irrigation, showed that only the type of product used was significantly associated with a change in skin condition. This is the first report of a controlled clinical study to evaluate the effect of pouching systems and patient/stoma variables on skin integrity in colostomy patients. These findings confirm that skin irritation can be a considerable problem, even in patients who use irrigation techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Pressure ulcers in extended care facilities: report of a survey

A survey including 15 extended care facilities with access to ET nurse consulting services was conducted to assess current wound care protocols, practices, and educational backgrounds as well as requirements. Sixty-seven percent of facilities surveyed used a system to describe pressure ulcers. Wound care was provided by licensed practical nurses in 90% of the institutions and product decisions were made by the physician in 65% of facilities surveyed. Gauze-type dressings were used most frequently on all stages and types of pressure ulcers. A significant correlation between ulcer type and dressings used was found for stage II pressure ulcers only. Hydrocolloid and polyurethane film dressings were more likely to be used on stage II ulcers without exudate than on any other type of ulcer (p < 0.001). The ET nurse and a variety of other professionals, including product manufacturer representatives, were consulted to assess complicated wounds. In 9 of 15 instances, the ET nurse was rated as the best source of practical wound care information. Respondents preferred wound care meetings that were practical, included all levels of health care providers, focused equally on treatment and prevention, and were not expensive to attend.

Full-thickness leg ulcers: patient demographics and predictors of healing. Multi-Center Leg Ulcer Study Group

BACKGROUND

Despite increased knowledge about the immediate and underlying causes of chronic leg ulcers, their management remains a challenge. Some ulcers rapidly respond to treatment whereas others do not, and the decision to reassess the patient and treatment modality is usually based on the clinician's own experience.

METHODS

Following diagnosis of the underlying cause of leg ulcers, 181 patients were screened. The use of a hydrocolloid dressing (DuoDERM) was evaluated in the treatment of 61 patients with 72 full-thickness ulcers. Patient characteristics associated with deep wounds as well as patient and wound characteristics predictive of the extent of healing and time required for healing were identified.

RESULTS

Patients with full-thickness ulcers were more likely to be overweight (P < .001) and not fully mobile (P = .016). During a mean treatment time of 56 days, 54% of the full-thickness ulcers healed. Ulcers were less likely to heal if the patients were men (P = .02) or had diabetes mellitus (P < .003). A > 30% reduction in ulcer area after 2 weeks of treatment was a predictor of both treatment outcome (P = .016) and time required for healing (P = .004). Odor at baseline and advanced age also were associated with increased time required for healing (P = .005 and .017, respectively).

CONCLUSIONS

Noninvasive clinical assessments can aid the clinician in predicting treatment outcome and may facilitate the decision to change therapy and evaluate treatment compliance.

Full-thickness pressure ulcers: patient and wound healing characteristics

To investigate the patient and healing characteristics related to full-thickness pressure ulcers, 119 consecutive patients admitted with ulcers in three acute care, four longterm care, and one rehabilitation agency were studied. Of the 119 patients with 153 pressure ulcers, only 48 (40%) had full-thickness ulcers. Compared to patients with partial-thickness ulcers, patients with full-thickness ulcers were more likely to have multiple ulcers, occasional incontinence of urine and feces, a compromised overall skin condition, and a less than optimal nutritional status at baseline. Full-thickness ulcers treated with a hydrocolloid dressing (DuoDERM Hydroactive) did not develop adverse reactions; clinicians perceived the dressing to be efficacious. Ulcers that healed during the study decreased 47% in area in two weeks. This distinguished ulcers that healed from those that did not heal. The findings suggest that ulcers that do not decrease in size within two weeks should be reevaluated for additional or alternate treatments.

Reading right: an exercise in critique

The previous critique of the "mini-article" merely scratches the surface with respect to critical reading of the literature. However, it is of vital importance to know whether the authors' conclusions are substantiated by the results obtained. Therefore, do not be intimidated by the data; pull out your calculator, verify the numbers, and practice your critical reading skills. After all, practice makes perfect!

Wound dressings: meeting clinical and biological needs

Central to any type of wound therapy is understanding the pathophysiology of healing and danger signals of the most common chronic wounds. This article discusses wound assessment, healing of acute and chronic wounds, factors that retard healing, and summarizes controlled clinical wound dressing literature.

Industry and dermatology research: how well can they work together?

Nursing roles in clinical research are expanding as biomedical technology advances and corporate funding for patient-oriented research increases. Collaboration between nurse investigators and industrial sponsors can lead to the successful application of new knowledge and improved health care if the objectives of both parties are understood and appropriate agreements ensue.

Evaluation of a new dressing in the treatment of sports-related skin lesions

Twenty-seven players with superficial wounds (abrasions, turf burns, and blisters) were treated with a new Hydroactive dressing. We conclude that this dressing provides an excellent alternative to other forms of treatment since it is easy to use, comfortable, hypoallergenic, and provides impressive healing results.

Multicenter clinical evaluation of a hydrocolloid dressing for leg ulcers

The need for a moist environment for the normal healing process led to the development of occlusive dressings. Results from this study support the contention that a moist wound environment is favorable to the healing process in humans as well as in animal models. Hydrocolloid dressings are effective in the practical daily management of chronic and even refractive ulcerations of the lower extremities and offer a time-saving treatment alternative with a high degree of patient acceptability.