Janet Ramundo

Enzymatic wound debridement

Background Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound. Objectives We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing. Search Strategy A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included. Results Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea–based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing. Implications for Practice Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.

Collagenase for enzymatic debridement: a systematic review.

Debridement is an essential component of wound bed preparation. Various techniques of debridement are commonly used in clinical practice. This systematic review summarizes and ranks evidence concerning the safety and efficacy of the selective enzymatic debriding agent collagenase. Studies were identified comparing collagenase to inactive (sham) ointment and to alternate techniques for debridement including autolytic and surgical. A preponderance of evidence from this systematic review confirms that collagenase ointment is a safe and effective choice for debridement of cutaneous ulcers and burn wounds.

Reliability and validity of the Braden Scale in the home care setting.

The Agency for Health Care Policy and Research guidelines for prediction and prevention of pressure ulcers have encouraged the use of risk assessment tools to identify those patients most likely to acquire a pressure ulcer. The Braden Scale has been widely tested and shown to be valid for use in acute and long-term care settings. Little data exist, however, on the use of the Braden Scale in the home care setting. This study determined the sensitivity and specificity of Braden Scale scores obtained for home care patients. Pressure ulcer incidence rate was 17%. Braden Scale scores ranged from 11 to 22. At a score of 18, sensitivity of the tool was 100%; the specificity was only 34%, however, indicating that the Braden Scale has validity in identifying patients at risk but has limited predictive ability.

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.

Is ultrasonic mist therapy effective for debriding chronic wounds

BACKGROUND Ultrasonic mist debridement uses acoustic energy to remove devitalized tissue from the wound bed and to promote wound healing. OBJECTIVES We systematically reviewed the literature to determine whether ultrasonic mist therapy effectively removes necrotic debris from the bed of chronic wounds and promotes wound healing. SEARCH STRATEGY A systematic review of electronic databases MEDLINE and CINAHL (from January 1996 to February 2008) was undertaken using the key words: (1) therapeutic ultrasound, (2) ultrasonic, and (3) ultrasonic mist. Prospective studies that compared ultrasonic mist therapy to a sham device, to another debridement technique, or to alternative treatments for wound healing were included. RESULTS There is insufficient evidence to determine whether ultrasonic mist therapy effectively debrides necrotic tissue in chronic wound beds. Limited evidence suggests that noncontact, low-hertz frequency ultrasonic mist therapy promotes wound healing when used in conjunction with standard wound therapy. IMPLICATIONS FOR PRACTICE Ultrasound treatment has been used on wounds associated with neuropathy, limb ischemia, venous insufficiency, trauma, as well as poorly healing surgical wounds. Few adverse effects have been noted. Pain, when reported, has been successfully addressed with topical analgesia.

WOCN Society and ASCRS Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Colostomy or Ileostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patients independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Colon and rectal surgeons and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Society of Colon and Rectal Surgeons and the American Urological Association, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

WOCN Society and AUA Position Statement on Preoperative Stoma Site Marking for Patients Undergoing Urostomy Surgery.

Marking the optimal location for a stoma preoperatively enhances the likelihood of a patients independence in stoma care, predictable pouching system wear times, and resumption of normal activities. Urologists and certified ostomy nurses are the optimal clinicians to select and mark stoma sites, as this skill is a part of their education, practice, and training. However, these providers are not always available, particularly in emergency situations. The purpose of this position statement, developed by the Wound, Ostomy and Continence Nurses Society in collaboration with the American Urological Association and the American Society of Colon and Rectal Surgeons, is to provide a guideline to assist clinicians (especially those who are not surgeons or WOC nurses) in selecting an effective stoma site.

Do Prophylactic Foam Dressings Reduce Heel Pressure Injuries

PURPOSE: The purpose of this evidence-based report card is to examine the evidence and provide recommendations related to the effectiveness of prophylactic foam dressings in reducing heel pressure injuries. QUESTION: Do prophylactic foam dressings applied to the heel reduce heel pressure injuries for patients in the acute care setting? SEARCH STRATEGY: A search of the literature was performed by a trained university librarian that resulted in 56 articles that examined pressure injury, prevention, and prophylactic dressings. A systematic approach was used to review titles, abstracts, and text, yielding 13 studies that met inclusion criteria. Strength of the evidence was rated based on the methodology from Essential Evidence Plus: Levels of Evidence and Oxford Center for Evidence-Based Medicine. FINDINGS: Thirteen studies were identified that met inclusion criteria; 1 was a randomized controlled trial, 2 were systematic reviews, 3 quasi-experimental cohort studies, 1 quality improvement study, 1 case series, 1 scoping review, 1 consensus panel, and 3 bench studies. All of the studies identified suggest that the use of prophylactic foam dressings reduces the development of pressure injuries on the heel when used in conjunction with a pressure injury prevention program. The strength of the evidence for the identified studies was level 1 (4 level A, 4 level B, and 5 level C). CONCLUSION/RECOMMENDATION: The use of prophylactic multilayer foam dressings applied to the heels, in conjunction with an evidence-based pressure injury prevention program, is recommended for prevention of pressure injuries on the heel (SORT level 1).

A look at the year

Virtually everyone reports to a boss, a board, or an oversight committee and many of us report to more than one. In my position as Editor of the Journal of Wound, Ostomy and Continence Nursing, I serve at the pleasure of the Officers and Directors of the WOCN Society. The Journal is a significant benefit for WOCN members (part of your Society dues pay for an annual subscription), and it is part of the Society’s estate (along with other enduring legacies). In addition to reporting regularly to the leadership of the WOCN, I believe it proper to report to the larger board, our subscribers. Reports to the WOCN Board, as you might expect, largely focus on matters of administrative process, costs, and profits. In contrast, my report to you, our readers, will primarily focus on the editorial process, followed by a call for papers designed to provide some insights into the priorities for Volume 35, which will begin with Issue 1 in January, 2008.