Paula Erwin-Toth

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.

Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study.

PURPOSE: The purpose of this study was to evaluate skin condition and quality of life following the use of a double-layer adhesive pouching system. This article reports results from North American participants. DESIGN: The study was an open-label, noncomparative, multicenter study. SUBJECTS AND SETTING: Seven hundred forty-three persons with ostomies who reside in North America participated in the study. INSTRUMENTS: A Stoma-Quality of Life (QOL) questionnaire consisting of 20 questions was used to measure health-related quality of life. The Ostomy Skin Tool was used to assess peristomal skin condition. METHODS: Peristomal skin and health-related quality of life were assessed by WOC nurses at baseline and again after 6 to 8 weeks following the use of a double-layer adhesive ostomy pouching system. The participants recorded self-reported leakage level, presence of peristomal skin disorder, use of appliance type (eg, convex, 1- or 2-piece), and frequency of consultation with the WOC nurse. RESULTS: Participants experienced a significant decrease in frequency of pouch leakage (P < .0001) and accessory use, improvement of skin condition, and overall significant improvement in mean quality of life score (56.8 vs 58.9, P < .0001). The greatest change on the Stoma-QOL scores was observed in the quartile of participants with the lowest QOL at baseline. Their QOL scores rose from a mean 43.8 at visit 1 to 50.1 at visit 2 (P < .0001). CONCLUSION: The combination of a regular contact with a WOC nurse and the use of a double-layer adhesive appliance led to a significant reduction in leakage and accessory use, improved skin condition, and significant improvement in health-related quality of life.

Management of patients with Bacilli Calmette-Guérin-refractory carcinoma in situ of the urinary bladder: Cost implications of a clinical trial for valrubicin

OBJECTIVE This study was undertaken to identify the expected first- and second-year clinical costs associated with intravesical valrubicin therapy, using a decision analytic model, for patients with Bacilli Calmette-Guérin (BCG)-refractory carcinoma in situ (CIS) of the urinary bladder. BACKGROUND Cancer of the urinary bladder is the fourth most common malignancy in men and the sixth most common noncutaneous carcinoma overall. One histopathologic stage of bladder cancer is CIS, for which BCG intravesical immunotherapy is the first-line therapy. Radical cystectomy has been recommended for patients with CIS who do not respond to or become refractory to therapy with BCG. Surgery, however, may not be appropriate for all patients, especially those who are ineligible for the lengthy procedure because of advanced age or comorbidities and those who prefer alternative nonsurgical management. For these groups, intravesical valrubicin therapy is a plausible alternative. METHODS Models were developed and populated with data from 1 open-label study of 90 patients, information from the medical literature, and input from clinical experts. The analysis was conducted from the payor perspective for direct costs only. RESULTS Our data indicate that first- and second-year expected costs for valrubicin therapy are

The pelvic pouch procedure and continent ostomies: Overview and controversies

19,912 and

Wound wise: Peristomal skin complications.

23,496, respectively. Expected cost for radical cystectomy was also evaluated, since some patients may have no other option if drug therapy fails. CONCLUSION Our cost-consequence analysis and clinical data provide decision-makers with tools to aid in global budgetary projections of fractional and total expected health care costs associated with the management BCG-refractory CIS of the urinary bladder.

Management of fistulae in the abdominal region.

The pelvic pouch and the continent ostomy provide reservoirs for fecal contents and avoid the need for traditional pouches. Patients with ulcerative colitis or familial polyposis coli now have the option of undergoing one of these procedures rather than a traditional ostomy. This article describes both procedures and covers preoperative and postoperative management, with emphasis on coordinated management by the ET nurse and surgeon.

Wound, Ostomy, and Continence/Enterostomal Therapy (WOC/ET) Nursing

Successful treatment can mean a successful ostomy.

Ostomy pearls: a concise guide to stoma siting, pouching systems, patient education and more.

OBJECTIVE We evaluated a new fistula and wound management system; ostomy and wound care nurses were queried about willingness to use the product in future patients, product wear time and pouch leakage, perifistular skin condition, access for wound care, pouching time, patient mobility and comfort, odor management, pouch flexibility, adhesiveness, and erosion. A health economic assessment was also done. METHOD Twenty-two patients (5 males and 17 females) with an abdominal fistula participated in the study. Participants tested 75 pouches, representing an average of 3.4 pouches per subject. The investigator at each site who performed the pouch changes completed a questionnaire at baseline, during the test, and after testing the pouches. Participants also completed a set of questions after each test pouch was removed. RESULTS In 21 of 22 cases, the nurses would consider using the new system on future patients. After each pouch removal, patients were asked whether they were able to move around while wearing the test pouch and they answered yes 95% of the time. The new system was found to have significantly longer wear time than traditional systems (P = .003), but the average time spent on changing the pouches was not significantly different (P = .07). Access for fistula and wound care was rated as excellent in the new pouching system, and comfort was rated as very good. CONCLUSION The results of the study suggest that all of the key requests received from nurses for an improved system for fistula and wound management were met by the new system.

The effect of ostomy surgery between the ages of 6 and 12 years on psychosocial development during childhood, adolescence, and young adulthood.

The specialty of enterostomal therapy nursing (ET), now known as wound, ostomy, and continence nursing (WOC), was founded in 1958 at Cleveland Clinic, Cleveland, Ohio. Pioneering colorectal surgeon Rupert B. Turnbull, M.D., joined forces with former patient Norma Gill to improve care and rehabilitate people with ostomies and enterocutaneous fistulae.