M. Gail Woodbury

Electrical Stimulation Therapy Increases Rate of Healing of Pressure Ulcers in Community-Dwelling People With Spinal Cord Injury

OBJECTIVE To investigate whether electric stimulation therapy (EST) administered as part of a community-based, interdisciplinary wound care program accelerates healing of pressure ulcers in people with spinal cord injury (SCI). DESIGN Single-blind, parallel-group, randomized, controlled, clinical trial. SETTING Community-based home care setting, Ontario, Canada. PARTICIPANTS Adults (N=34; mean age +/- SD, 51+/-14y) with SCI and stage II to IV pressure ulcers. INTERVENTIONS Subjects were stratified based on wound severity and duration and randomly assigned to receive either a customized, community-based standard wound care (SWC) program that included pressure management or the wound care program plus high-voltage pulsed current applied to the wound bed (EST+SWC). MAIN OUTCOME MEASURES Wound healing measured by reduction in wound size and improvement in wound appearance at 3 months of treatment with EST+SWC or SWC. RESULTS The percentage decrease in wound surface area (WSA) at the end of the intervention period was significantly greater in the EST+SWC group (mean +/- SD, 70+/-25%) than in the SWC group (36+/-61%; P=.048). The proportion of stage III, IV, or X pressure ulcers improving by at least 50% WSA was significantly greater in the EST+SWC group than in the SWC group (P=.02). Wound appearance assessed using the photographic wound assessment tool was improved in wounds treated with EST+SWC but not SWC alone. CONCLUSIONS These results demonstrate that EST can stimulate healing of pressure ulcers of people with SCI. EST can be incorporated successfully into an interdisciplinary wound care program in the community.

Which Reported Estimate of the Prevalence of Malnutrition After Stroke Is Valid

Background and Purpose— The reported prevalence of malnutrition after stroke varies widely, whereas it remains unclear which of the estimates is most accurate. The aim of this review was to explore possible sources of this heterogeneity among studies and to evaluate whether the nutritional assessment techniques used were valid. Methods— A literature search was conducted to identify all studies in which the nutritional state of patients was assessed after inpatient admission for stroke. The percentages of patients identified as malnourished in each study and method of nutritional assessment are reported. For the purposes of this study, an assessment technique was considered valid if at least one form of validity had been demonstrated previously through psychometric evaluation. Results— Eighteen studies meeting inclusion criteria were identified. The reported frequency of malnutrition ranged from 6.1% to 62%. Seventeen different methods of nutritional assessment were used. Four trials used previously validated assessment methods: Subjective Global Assessment, “an informal assessment,” and Mini Nutritional Assessment. The nutritional assessment methods used in the remaining studies used had not been validated previously. Conclusions— The use of a wide assortment of nutritional assessment tools, many of which have not been validated, may have contributed to the wide range of estimates of malnutrition. If so, this underscores the need for valid and reliable assessment tools to further our understanding of the relationship between stroke and nutritional status.

Measuring Longitudinally the Metabolic Demands of Stroke Patients Resting Energy Expenditure Is Not Elevated

Background and Purpose— Little is known of the acute, subacute, and longer-term energy demands of stroke, information essential to appropriate clinical and nutritional management. The goals of this study were to (1) determine the resting energy expenditure (REE) of stroke patients from stroke onset to 3 months, (2) examine relations between stroke size, type, location, severity, and REE, and (3) evaluate whether estimation of REE from the Harris-Benedict equation (HB) requires the addition of a “stress factor” to capture the possible additional REE imposed by stroke. Methods— The REE of new stroke patients was measured prospectively at hospital admission and on days 7, 11, 14, 21, and 90 by indirect calorimetry. Stroke patients’ REEs (Kcal/d) over time and REEs as a percentage of HB were compared with control subjects’ single measurements. Results— Mean REE and %HB of stroke patients ranged from 1521±290 to 1663±268 Kcal/d and from 107±14.9 to 114±12.9 %HB, respectively. Mean measurements of control subjects were 1665±265 Kcal/d and 112.9±11.4 %HB (NS). REE was not associated with stroke characteristics (NS). Changes in REE measured longitudinally were not clinically meaningful (4 to 62 Kcal/d) though statistically significant (P =0.004). Conclusions— The REEs of stroke patients and controls were both ≈10% higher than those predicted by HB. No hypermetabolic response pattern of energy expenditure was evident after stroke. REE did not vary with stroke characteristics, although confirmation with larger subgroups is required.

Development, validity, reliability, and responsiveness of a new leg ulcer measurement tool.

OBJECTIVE:To develop and validate an assessment tool—the Leg Ulcer Measurement Tool (LUMT)—that would be able to detect changes in the appearance of lower extremity ulcers. SUBJECTS:Twenty-two subjects with chronic leg ulcers of various etiologies (arterial, venous, diabetes) participated in the validation study. DESIGN:An interdisciplinary panel consisting of 9 local wound care specialists confirmed content validity. Concurrent criterion validity was determined by correlation of the size domain (1 of 14 clinician-rated domains in the LUMT) with acetate tracing measurement of wound surface area. Reliability was determined using repeated assessments by 4 wound care specialist and 2 inexperienced evaluators; responsiveness was determined using monthly reassessments by a single rater for 4 months. RESULTS:Concurrent criterion validity was r = 0.82. Excellent values of intrarater and interrater reliability (ICC > 0.75) were obtained for total LUMT scores and for many of the 14 individual domains; however, several domains were found to be less reproducible. The LUMT detected change in wound status over time (responsiveness coefficient = 0.84). CONCLUSION:The LUMT can be used by 1 or more assessors, with relatively little previous training, to make reproducible evaluations of lower extremity ulcer appearance and to document change in appearance over time. The LUMT represents a novel assessment tool specifically designed and validated for clinical or research use on chronic leg ulcers.

Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings.

BackgroundIn long-term care (LTC) homes in the province of Ontario, implementation of the Minimum Data Set (MDS) assessment and The Braden Scale for predicting pressure ulcer risk were occurring simultaneously. The purpose of this study was, using available data sources, to develop a bedside MDS-based scale to identify individuals under care at various levels of risk for developing pressure ulcers in order to facilitate targeting risk factors for prevention.MethodsData for developing the interRAI Pressure Ulcer Risk Scale (interRAI PURS) were available from 2 Ontario sources: three LTC homes with 257 residents assessed during the same time frame with the MDS and Braden Scale for Predicting Pressure Sore Risk, and eighty-nine Ontario LTC homes with 12,896 residents with baseline/reassessment MDS data (median time 91 days), between 2005-2007. All assessments were done by trained clinical staff, and baseline assessments were restricted to those with no recorded pressure ulcer. MDS baseline/reassessment samples used in further testing included 13,062 patients of Ontario Complex Continuing Care Hospitals (CCC) and 73,183 Ontario long-stay home care (HC) clients.ResultsA data-informed Braden Scale cross-walk scale using MDS items was devised from the 3-facility dataset, and tested in the larger longitudinal LTC homes data for its association with a future new pressure ulcer, giving a c-statistic of 0.676. Informed by this, LTC homes data along with evidence from the clinical literature was used to create an alternate-form 7-item additive scale, the interRAI PURS, with good distributional characteristics and c-statistic of 0.708. Testing of the scale in CCC and HC longitudinal data showed strong association with development of a new pressure ulcer.ConclusionsinterRAI PURS differentiates risk of developing pressure ulcers among facility-based residents and home care recipients. As an output from an MDS assessment, it eliminates duplicated effort required for separate pressure ulcer risk scoring. Moreover, it can be done manually at the bedside during critical early days in an admission when the full MDS has yet to be completed. It can be calculated with established MDS instruments as well as with the newer interRAI suite instruments designed to follow persons across various care settings (interRAI Long-Term Care Facilities, interRAI Home Care, interRAI Palliative Care).

Implementation of best practice in the prevention of heel pressure ulcers in the acute orthopedic population

To implement and evaluate a heel pressure ulcer prevention program (HPUPP) for orthopaedic patients. Program development of HPUPP involved input from administrators, staff and adult patients on an orthopaedic service in an academic tertiary care facility, located in a small urban centre in Canada. Prospective evaluation was conducted. Consensus exercises with clinical staff and administrators (Delphi and Nominal group) were used to, evaluate current practices, select a heel protective device, and develop key aspects of the HPUPP. HPUPP involved an individualised, bedside, staff education program, a team approach to improve patient mobility and use of a heel protective device. A 2‐inch foam wedge covered in washable vinyl was placed at the foot of all beds on the orthopedic service. After the program was implemented, the incidence of heel pressure ulcers was 0%, which was a significant reduction compared with pre‐implementation levels [13·8% (95% confidence interval 8–18%)]. Key components of the program success were initial and ongoing support from administration and surgeons, incorporation of feedback from clinical staff and patients, and keeping the program simple. Heel PU can be prevented in most orthopaedic patients using a universal heel PU prevention program.

The use of topical 4% lidocaine in spheno-palatine ganglion blocks for the treatment of chronic muscle pain syndromes : a randomized, controlled trial

&NA; To assess the efficacy of 4% topical lidocaine in spheno‐palatine blocks, a randomized controlled trial was carried out on patients with chronic muscle pain syndromes. Sixty‐one patients (42 with fibromyalgia (FM) and 19 with myofascial pain syndrome (MPS)) completed the trial. Outcome measures included pain intensity, a daily pain diary, headache frequency, sensitivity to pressure using a dolorimeter, anxiety, depression, and sleep quality. Patients were randomized to receive either 4% lidocaine or sterile water (placebo) 6 times over a 3‐week period. Both subjects and investigators were blind to treatment allocation. The results showed that 4% lidocaine had no superiority over placebo in any of the outcome measures. Twenty‐one subjects (35%) showed a decrease in pain which was greater than 30% of their baseline value. Of these 21 subjects, 10 received lidocaine and 11 received placebo. These data suggest that, in this population, 4% lidocaine is no better than placebo in the treatment of chronic muscle pain.

The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis

This meta‐analysis investigated the effectiveness of a pressure‐relieving intervention on the incidence of heel pressure ulcers in a variety of settings. Literature searches of Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PubMed, EMBASE and Cochrane databases were conducted for English‐language articles that investigated the effect of pressure relief interventions with or without concurrent prevention programs on the number of heel ulcers occurring on adult humans in a controlled clinical design. Full articles were selected from citations based upon consensus between at least two independent reviewers. Methodological quality of each study was assessed using the Jadad and PEDro scales. A quantitative analysis was performed to determine and compare relative risk (RR) between pressure relief programs/devices that were classified according to similarity of interventions. Fourteen studies that involved a total of 1457 subjects were selected from a total of 105 full articles reviewed. Pressure‐reducing/relieving surfaces were associated with a significantly lower incidence of heel ulcers compared with standard hospital mattresses (RR = 0·50, 95% CI = 0·26–0·93, P < 0·03). Foam mattresses also significantly reduced the risk of developing heel ulcers. There is evidence to support the use of certain air or foam mattresses/overlays in the prevention of heel pressure ulcers when compared with a standard hospital mattress. There is insufficient research available at this time to determine if heel‐protective devices can prevent heel pressure ulcers. These results need to be interpreted with caution given the relatively low number and poor quality of research articles available to date.

Reliability and predictive validity of Inlow's 60-Second Diabetic Foot Screen Tool.

OBJECTIVE: The purpose of this study was to assess Inlow’s 60-Second Diabetic Foot Screen Tool to ascertain consistency of risk recognition for development of ulceration independent of specific assessor and practice setting. Screening tools that assist clinicians in identifying risk require validation. The objectives were to determine the intrarater reliability, interrater reliability, and predictive validity of Inlow’s 60-Second Diabetic Foot Screen Tool in 2 healthcare settings. DESIGN: Following ethics board approval, a prospective observational study was completed. SETTING AND PARTICIPANTS: A convenience sample of 69 persons with diabetes was recruited: n = 26 from an acute care setting (dialysis) and n = 43 from long-term-care (LTC) setting. MAIN OUTCOME MEASURES: The screening tool was administered by 2 assessors independently to determine interrater reliability and later the same day by one of the assessors to determine intrarater reliability. Occurrence of foot ulcers or amputation was noted 1 to 5 months later to determine predictive validity. MAIN RESULTS: Reliability is reported per setting using the intraclass correlation coefficient (2.1) and 95% confidence intervals. Intrarater reliability: LTC 0.96 (0.93–0.98) right foot, 0.97 (0.95–0.98) left foot; dialysis 1.00 right and 1.00 left foot. Interrater reliability: LTC 0.92 (0.86–0.96) right foot, 0.93 (0.87–0.96) left foot; dialysis 0.83 (0.65–0.92) right foot and left foot. Predictive validity: Two subjects had events—1 ulcer and 1 amputation—that were associated with high Inlow’s screening tool scores. CONCLUSION: This study demonstrates excellent interrater and intrarater reliability and provides preliminary information about predictive validity.

Pressure ulcer awareness and prevention program: a quality improvement program through the Canadian Association of Wound Care.

The Canadian Association of Wound Care funded a study to determine the extent of pressure ulcers in Canada and discovered that the mean prevalence rate was 26%. Recognizing this as a significant health-related problem, the Canadian Association of Wound Care created a continuous quality improvement program known as the Pressure Ulcer Awareness and Prevention program to support a culture shift in healthcare settings, that is, shifting the emphasis on management from treatment of existing ulcers to their prevention. This program has been pilot tested, revised, and is being implemented in many Canadian healthcare facilities. The program is described and results are presented that demonstrate a reduction rate up to 57% (prevalence) and 71% (incidence).