Laura Bolton

Wound-healing outcomes using standardized assessment and care in clinical practice.

INTRODUCTION Wound-healing outcomes applying standardized protocols have typically been measured within controlled clinical trials, not natural settings. Standardized protocols of wound care have been validated for clinical use, creating an opportunity to measure the resulting outcomes. PURPOSE Wound-healing outcomes were explored during clinical use of standardized validated protocols of care based on patient and wound assessments. DESIGN This was a prospective multicenter study of wound-healing outcomes management in real-world clinical practice. METHOD Healing outcomes from March 26 to October 31, 2001, were recorded on patients in 3 long-term care facilities, 1 long-term acute care hospital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms. After diagnosis, wound dimensions and status were assessed using a tool adapted from the Pressure Sore Status Tool for use on all wounds. Wound, ostomy, and continence nursing professionals accessed consistent protocols of care, via telemedicine in home care or paper forms in long-term care. A physician entered assessments into a desktop computer in the wound clinic. Based on evidence that healing proceeds faster with fewer infections in environments without gauze, the protocols generally avoided gauze dressings. RESULTS Most of the 767 wounds selected to receive the standardized-protocols of care were stage III-IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). Partial-thickness wounds healed faster than same-etiology full-thickness wounds. CONCLUSIONS These results provide benchmarks for natural-setting healing outcomes and help to define and address wound care challenges. Outcomes primarily using nongauze protocols of care matched or surpassed best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.

Prospective, Multicenter Study of Managing Lower Extremity Venous Ulcers

Seventy patients with 90 venous ulcers were randomly assigned to hydrocolloid or conventional dressing and compression therapy at four study centers. The ulcers had been present for a mean of 47.8 in the control and 46.2 weeks in the treatment group and 42% of all patients had recurrent ulcers. Ulcers treated with hydrocolloid dressings reduced 71% and control treated wounds reduced 43% in area after 7.2 weeks of treatment. Thirty-four percent of all ulcers healed. Mean time to healing was 7 weeks for the hydrocolloid dressing group and 8 weeks for the control group. Most ulcers were less painful at final evaluation, but reduction in pain was more pronounced in hydrocolloid-dressed ulcers (p=0.03). At baseline as well as during follow-up, significant differences between study centers were observed. Ulcers in patients in the United Kingdom were larger and less likely to heal (p=0.001). Size of the ulcer at baseline was associated with treatment response and time to healing (p=0.002). Percent reduction in ulcer area after 2 weeks was also correlated with treatment outcome (p=0.004) and time to healing (p=0.002). When all treatment outcome predictors were analyzed together, only percent reduction in area after 2 weeks remained statistically significant (p=0.002), with percent reduction during the first 2 weeks of treatment >30% predicting healing.

Topical hydrogen peroxide treatment of ischemic ulcers in the guinea pig : blood recruitment in multiple skin sites

BACKGROUND Oxygen deficit is a key factor associated with delayed healing of ischemic wounds in human beings. Topical oxygen-releasing compounds such as hydrogen peroxide or tetrachlorodecaoxide have been suggested as therapy for ischemic tissue. OBJECTIVE Our purpose was to monitor the effect of hydrogen peroxide cream on the process of ischemic ulcer healing with a model for ischemic ulcers in the guinea pig. METHODS Measurement of vascular perfusion with a laser Doppler velocimeter and gross observations of percentage of nonnecrotic wound surface were made on ischemic wounds in guinea pigs after treatment with either a hydrogen peroxide cream or a placebo cream. RESULTS Visual evaluations of the percentage of nonnecrotic wound surface showed no statistically significant differences among the treatments. In contrast, vascular perfusion measurements resulted in statistically significant differences. Blood flow was significantly higher up to day 15 in ulcers treated with 2% hydrogen peroxide cream than in those treated with placebo cream. Vascular perfusion was significantly higher in ulcers treated with 3.5% hydrogen peroxide cream than in ulcers treated with either 1.5% hydrogen peroxide cream or placebo. Adjacent control sites in guinea pigs whose ulcers were treated with hydrogen peroxide cream showed increased vascular perfusion compared with corresponding sites in animals whose ulcers were treated with placebo. Even distant flank control sites of ulcers treated with 3.5% hydrogen peroxide cream showed increased vascular perfusion. CONCLUSION Treatment of ischemia-induced ulcers with hydrogen peroxide cream enhanced cutaneous blood recruitment not only to ulcers and adjacent sites, but also to distant sites.

Options for diabetic patients with chronic heel ulcers

The presence of a heel ulcer in the diabetic patient is usually due to neuropathy, vasculopathy, or both. Diagnostic testing including noninvasive assessment by nerve conduction velocity and Doppler pressure measurements can provide the basis for subsequent treatment. The diagnosis of osteomyelitis is assisted by plain radiographs, isotope definition, and/or magnetic resonance imaging (MRI). The loss of the calcaneus may mean loss of the functioning foot. Reconstructive arterial surgery for heel lesions in the diabetic patient has limited success. Prevention and local wound care, along with patient education, will result in limb salvage and the prevention of disability.

Which pressure ulcer risk assessment scales are valid for use in the clinical setting

QuestionsWhat are the most reliable valid scales for assessing pressure ulcer risk?Based on available evidence, how should pressure ulcer risk assessment scales (PURAS) be used?Does use of a PURAS guide preventive interventions?

Operational definition of moist wound healing.

Ancient civilizations ameliorated the adverse effects of allowing wounds to dry by adding saps, resins, or ointments to the cloth dressings they applied.1 Thomas Baynton first applied moisture-retentive adhesive tape to venous ulcers in 1797.2 Nearly 150 years later, Oscar Gilje, a Norwegian dermatologist, published scientific confirmation that areas of more than 200 venous ulcers covered with adhesive tape beneath Unna’s boot healed faster than areas of the same ulcers managed without the adhesive tape. Numerous controlled studies in the last 50 years established moist wound healing (MWH) as the best evidence-based practice.3,4 It makes biological sense to provide a moist physiological environment for the cells that do the work of healing by preventing wounded tissue from drying5 or incorporating gauze fibers6 into healing tissue. Dried wound tissue is more prone to complications such as infection,7 scarring,8 or pain9 and heals more slowly10 than moist tissue, placing patients at risk of longer hospital stays or amputations. Yet medical professionals have been slow to adopt this evidence partly because MWH means different things to different professionals. One protocol may call wet-to-dry gauze MWH, whereas another specifies hydrocolloid or film dressings as MWH. Which is right? A major cause of confusion is a lack of a unified operational definition for MWH that is reliably associated with clinical healing outcomes. Biology, physics, and chemistry surged forward with clear operational definitions all could use to test the hypotheses about the way the world works. Imagine what wound care could accomplish if we all spoke the same language and “walked the talk.” The Wickipedia defines “operational definition” as “a description of something— such as a variable, term, or object—in terms of the specific process or set of validation tests used to determine its presence and quantity.” All who repeat the process or set of validation tests should get the same results. For example, an operational definition of an object’s weight in grams is to record the result when it is placed on a scale graduated in grams. This process or operation defines the object’s weight. Therefore, in order to derive an operational definition for MWH, it is necessary to search the literature for processes used to keep a wound moist, and identify those processes that optimize healing outcomes.

Are silver products safe and effective for chronic wound management

Summary The literature on effects of silver-containing modalities onsafety or efficacy in pressure ulcer, venous ulcer, or dia-betic ulcer is sparse. There are few controlled studies, and inthe modalities studied control protocols on the safety andefficacy measures vary across studies, rendering a meta-analysis of the data inappropriate at this time. Despite theselimitations, uncontrolled studies on more than 58 pressureulcers, 213 venous ulcers, and 108 diabetic foot ulcers gen-erally support the safety of one silver foam dressing (n = 50),one Hydrofiber dressing with ionic silver (n = 246), one sil-ver nylon dressing (n = 30), one collagen/cellulose/silverdressing (n = 23), and one silver-impregnated tulle gauze(n = 30). Nevertheless, small sample sizes and limitations inresearch methodology indicate caution when interpretingthese findings for the present. Moreover, caution is advisedbefore generalizing these findings to conclusions aboutother silver product safety measures.Limited evidence was identified supporting the efficacyof silver products for certain chronic wounds. One RCT sup-ports the conclusion that pressure ulcers decrease in woundarea faster if dressed with a silver-foam dressing than with avariety of other modalities with or without silver. The ef-fects of silver on pressure ulcers remain to be clarified in amore precisely controlled study. Another RCT on venousulcer (n = 65) and one on mixed pressure ulcer and venousulcer support the conclusion that a silver-foam dressing im-proves venous ulcer healing. One more RCT appears to sup-port this conclusion, but the variety of control productsobscures the effects of silver on venous ulcers. Two RCTs ona total of 119 diabetic ulcers reported an effect on one as-pect of diabetic ulcer healing: faster depth reduction in di-abetic ulcer dressed with a silver Hydrofiber dressing. Twoother RCTs support silver-foam effects on reduced diabeticulcer slough and maceration, and an activated charcoal sil-ver dressing effect on reducing wound bacteria,

Compression in venous ulcer management.

Venous ulcers (VU) resulting from compromised venous circulation affect up to 1% of the population over 60 years of age.1,2 They cost approximately 2.5 to 3.5 billion US health care dollars annually,3 and they profoundly diminish quality of life and functional status.4,5 Compression is seen as the cornerstone of therapy for managing VU,6 yet use and reimbursement of effective compression modalities for both treating VU7 and preventing VU recurrence8 remains inconsistent. Despite abundant research, uncertainty remains about what types of compression modalities are likely to derive optimal healing outcomes on an individual patient and what appropriate usage parameters are likely to work best for the modality selected. This Evidence-Based Report Card summarizes clinical evidence supporting VU healing efficacy reported using various types of compression modalities.

Quantification of Wound Healing

Scientific study has improved cutaneous wound healing outcomes more since 1948 than at any time in recorded history. To accomplish this, scientists and clinicians measured the outcomes of healing and its intermediary processes and carefully documented what treatments yielded the best results and what measured changes were correlated with clinical healing (e.g., Bates-Jensen, 1997). In order to measure effects of any treatment on healing, one must quantify the aspect of healing affected. This chapter summarizes reliable, valid techniques for quantifying cutaneous repair and its mediating events so that clinicians and scientists can use these same principles to further elucidate and improve wound healing outcomes based on the best available evidence

BURDEN OF PRESSURE ULCER CARE: 683

healthcare setting affect more than 2 million Americans per year. One of the major healthcare initiatives is to decrease the rate of surgical site infections. It is to this purpose that our study was undertaken. METHODOLOGY: This was a quasi-experimental study with before/after design. Convenience sampling of patients that had pain implemented device surgery was obtained from 1999-2003 prior to intervention implementation and those patients in 2004 postintervention implementation. Retrospective record review was conducted on patients prior to intervention being implemented and post-intervention implementation. Review utilized CDC guideline and definition for surgical site infection to identify surgical site infection. STATISTICS: The data were analyzed using descriptive statistics and Chi-square. The before-intervention group was compared to the after-intervention group. RESULTS: Sixty-four patients participated in this study. In the before-intervention group, 16% surgical site infection rate was identified. In the afterintervention group, 9% surgical site infection rate was identified. CONCLUSION: The findings suggest that the use of antimicrobial barrier film dressing can reduce the rate of surgical site infections when used for postoperative pain implanted devices surgical sites.