Negative pressure wound therapy (NPWT) uses negative pressure to draw wound edges together, remove edema and infectious material, and promote perfusion and granulation tissue development. The tissue stretch and compression created by negative pressure during NPWT promotes tissue perfusion and granulation tissue development through angiogenesis, cellular proliferation, fibroblast migration, increased production of wound healing proteins, and reduction of wound area. NPWT has been used to improve healing in a variety of wounds, including traumatic injuries, surgical wounds, pressure ulcers, diabetic foot ulcers, and venous stasis ulcers. (more…)
Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria. (more…)
Complex wound failures are costly and time-consuming. They increase length of stay and contribute to morbidity and mortality in surgical patients. Negative-pressure wound therapy (NPWT)—a common adjunct to wound-care therapy—is used to accelerate wound healing in all fields of surgery. Using a vacuum device and wound-packing material, it applies subatmospheric pressure to complex wounds.
But NPWT alone doesn’t ensure adequate wound healing. Many physiologic factors—including infection, excessive moisture, nutrition, and medications—influence wound-healing success. Failure to account for these factors or improper application of NPWT can limit patient outcomes and cause debilitating complications.
For clinicians, applying and establishing an airtight seal on a complex wound is among the most dreaded, time-consuming, and challenging NPWT-related tasks. Simply applying NPWT material under layers of transparent drape may delay wound healing or exacerbate the wound. This article provides tips on safe application of NPWT to enhance the outcomes of patients with complex wounds.
Consider wound location
Wounds on the body’s anterior surfaces are less susceptible to the forces of pressure, friction, and shear than those on posterior and lateral surfaces. Posterior and lateral wounds commonly require posterior offloading or repositioning the patient in bed to reduce or eliminate direct pressure. This can be done with judicious and frequent patient turning using a specialty bed or support surface.
Bridge a posterior or lateral wound to an anterior surface by placing the drainage collection tubing to a nonpressure-bearing surface away from the wound. Bridging keeps the tubing from exerting pressure on intact skin and decreases the risk of a pressure ulcer. To create the bridge, cut foam into a single spiral of 0.5 to 1 cm, or if using gauze, fold gauze into 8 single layers.
Place the spiraled foam or gauze layers onto the drape, ensure the bridge is wider than the collection tubing disc, and secure it with an additional drape. Next, apply the NPWT collection tubing on the end of the bridge away from the wound. A wide bridge under the collection tubing disc will minimize the potential for periwound breakdown when negative pressure is initiated. You may modify this spiraling technique by varying the width of the foam to fill undermining and wounds of irregular configuration and depth.
Protect the periwound
An intact periwound may break down from exposure to moisture, injury from repetitive removal of a transparent drape, or NPWT material coming in contact with skin. Skin protection is critical in preventing additional breakdown stemming from contact with potentially damaging material.
Transparent drapes are designed to permit transmission of moisture vapor and oxygen. Avoid using multiple layers of transparent drapes to secure dressings over intact skin, as this can decrease the transmission of moisture vapor and oxygen, which in turn may increase the risk of fungal infection, maceration, and loss of an intact seal.
Periwound maceration also may indicate increased wound exudate, requiring an increase in negative pressure. Conversely, an ecchymotic periwound may indicate excessively high negative pressures. If either occurs, assess the need to adjust negative pressure and intervene accordingly. Reassess NPWT effectiveness with subsequent dressing changes.
Apply a protective liquid skin barrier to the periwound and adjacent healthy tissue to help protect the skin surface from body fluids. The skin barrier also helps prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes. Excessive moisture can be absorbed by using a light dusting of ostomy powder sealed with a skin barrier. A “window pane” of transparent drape or hydrocolloid dressing around the wound also can protect surface tissue from contactwith NPWT material and prevent maceration.
Avoid creating rolled wound edges
In the best-case scenario, epithelial tissue at the wound edge is attached to the wound bed and migrates across healthy granulation tissue, causing the wound to contract and finally close. With deep wound environments that lack moisture or healthy granulation tissue, the wound edges may roll downward and epibole may develop. Epibole is premature closure of the wound edges, which prevents epithelialization and wound closure when it comes in contact with a deeper wound bed. (See Picturing epibole by clicking the PDF icon above.)
Materials used in NPWT are primarily air-filled. Applying negative pressure causes air removal, leading to wound contraction by pulling on the wound edges—an action called macrostrain. Without sufficient NPWT material in the wound, macrostrain can cause the wound to contract downward and the wound edges to roll.
Ensure that enough NPWT material has been applied into the wound to enhance wound-edge approximation and avoid creating a potential defect as the wound heals. Before NPWT begins, material should be raised 1 to 2 cm above the intact skin. Additional material may be needed with subsequent changes if the NPWT material compresses below the periwound. The amount of NPWT material needed to remain above the periwound once NPWT starts varies with the amount of material compressed and the wound depth.
Reduce the infection risk
To some degree, all wounds are contaminated. Usually, the body’s immunologic response is able to clear bacterial organisms and wound healing isn’t delayed. But a patient who has an infection of a complex wound needs additional support.
Systemic antibiotics alone aren’t enough because they’re selective for specific organisms and don’t reach therapeutic levels in the wound bed. In contrast, topical antimicrobial adjuncts, such as controlled-release ionic silver, provide broad-spectrum antimicrobial coverage against fungi, viruses, yeasts, and gram-negative and gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.
Consider using controlled-release ionic silver for a wound known to be infected or at risk for infection due to its location or potential urine or fecal contamination. To be bactericidal, ionic silver must be in concentrations of at least 20 parts per million; also, it must be kept moist and must come in direct contact with infected wound bed. At lower concentrations, organisms may develop resistance. Ionic silver has no known resistance or contraindications. Dressings using it come in several forms, including a hydrogel sheet, perforated sheet, cavity version, and semiliquid hydrogel. Be sure the form you choose doesn’t occlude the NPWT material and compromise therapy. (See NPWT for a patient with necrotizing fasciitis by clicking the PDF icon above.)
One of the most daunting aspects of NPWT is obtaining and maintaining a good seal—in other words, avoiding the dreaded leak. Preventive skin measures may contribute to a poor seal; skin-care products containing glycerin, surfactant, or dimethicone may prevent adequate adhesion of NPWT drapes. Body oil, sweat, and hair may need to be minimized or removed.
To avoid leaks, don’t overlook the obvious—loose connections, a loose drainage collection canister, exposed NPWT material, and skinfolds extending beyond the transparent drape. Tincture of benzoin (with or without a thin hydrocolloid dressing) increases tackiness to enhance the adhesive property of a transparent drape on the diaphoretic patient and on hard-to-drape areas, such as the perineum. But be sure to use tincture of benzoin with discretion, as it may remove fragile periwound tissue when the dressing is removed.
Ostomy paste products can serve as effective filler. These pliable products can be spread into position to obtain a secure seal under the transparent drape in hard-to-seal areas, such as the perineum. Pastes remain flexible and can be removed without residue. Temporarily increasing NPWT pressure to a higher setting may help locate a subtle leak or provide enough negative pressure to self-seal the leak. Once the leak resolves, remember to return the pressure to the ordered setting.
Knowledge optimizes healing
It’s important to be aware of potential complications of NPWT (See Take care with NPWT by clicking on the PDF icon above). However, when applied correctly, NPWT is an effective option for managing complex wounds. Recognizing and managing potential complications at the wound site, ensuring periwound protection, minimizing epibole formation, and preventing wound infection can result in a better-prepared wound bed and promote optimal healing.
Selected references
Baranoski S, Ayello EA. (2012). Wound Care Essentials: Practice Principles. 3rd ed. Springhouse, PA; Lippincott Williams & Wilkins.
Bovill E, Banwell PE, Teot L, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J. 2008;5:511-529.
Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Baltimore, MD; Lippincott Williams & Wilkins; 2011.
Ronald Rock is an Adult Health Clinical Nurse Specialist in the Digestive Disease Institute at the Cleveland Clinic in Cleveland, Ohio.
Jim, a 52-year-old patient with colon cancer, received a new ostomy. He needed a custom fit for his appliance, which took 10 days. During this time, trying to obtain a good seal and treat the peristomal area wasn’t easy. Despite my best efforts, Jim’s skin was denuded from contact with stool. Although he was in great discomfort, he wanted to wait until my next visit to tell me about the problem. Fortunately, his wife was worried and contacted me directly.
Jim lives in a neighborhood with a low crime rate, so I’m able to see him within a few hours of his wife’s call, even though it’s late at night. As it turns out, I make extra visits to help him manage his stoma until the customized appliance is ready.As with any home care situation, I’m ready to do my best for my patient.
Many home-care patients like Jim benefit from the interventions of a wound care clinician (WCC). More than one-third of all home-care admissions are wound related, and home wound care has become one of the fastest growing needs and skills in home-care services. So if you’re a WCC, you may want to consider home care as a practice option.
Delivering wound care in the home differs dramatically from delivering it in the hospital. Given the complexity of wound care and the multiple factors that affect healing, home wound care is a challenge. Some patients have chronic conditions, such as diabetes or wounds or open sores that don’t heal easily. In other cases, the patient or caregiver is unable to change dressings. That’s where the WCC comes in.
Special needs of home-care patients
Like other patients across the continuum of care, home-care wound patients require accurate and thorough wound assessment, as well as documentation that provides information about wound status and aids development of a plan that supports healing.
Of course, the plan of care must address the whole patient, not just the “hole” in the patient. The WCC must take into account comorbidities, individual wound-care requirements, assistance the patient may need due to physical or mental deficits, and nutritional support. Additional factors that affect wound-care strategies include wound characteristics, family support, and insurance guidelines and reimbursement.
Role of the WCC
The WCC’s role in home care includes providing clinical expertise, working with other healthcare team members, and providing education.
The WCC provides clinical expertise regarding wound and ostomy care to ensure delivery of the highest quality of care. This expertise helps reduce the need for readmissions to the emergency department (ED) for wound-related complications. The WCC also plays a vital role in product awareness, formu-lary development, and maintenance of cost-effective, evidence-based practice in the agency.
Working with other healthcare team members, the WCC serves as patient advocate, strengthening the relationship between patient and healthcare team members while promoting care coordination to help the patient achieve goals. Effective communication with the patient’s primary care provider is essential to delivering the best-quality, research-based wound care. A tool for strengthening such communication is the SBAR (Situation-Background-Assessment-Recommendation) technique. SBAR structures conversations so all parties provide complete yet concise information. (See SBAR wound and skin provider communication record by clicking the PDF icon above).
The WCC educates patients and family members about wound healing, dressing applications, and other interventions. Teaching families allows them to be involved in the patient’s care and start to take ownership of it. The WCC also educates home health aides, who can play a vital role in preventing such problems as pressure ulcers and may be responsible for ensuring staff members are aware of the products, procedures, and dressings available.
Challenges of home care
If you’re a WCC and considering home care as a career option, know that practicing in the home can be a real eye opener. For starters, consider geography. Shortly after I started as a wound care nurse/consultant in home care, I was visiting patients all over New Jersey, some days driving 200 miles. As I quickly discovered, once you enter the home, don’t assume you’ll simply change a dressing and then be on your way. Instead, you may find you are, in essence, the family case manager who’s expected to “fix everything.” This role requires equal doses of planning and creativity.
What’s more, expect to do some improvising. In acute-care settings, all the supplies you may need to prevent infection—gowns, gloves, masks—usually are within arm’s reach. But in home care, these supplies may be absent, meaning you’ll need to set up the cleanest environment you can under the circumstances. That might mean using disposable drapes and dressings. Be sure to carry large amounts of hand sanitizer.
Dressing selection is perhaps the biggest challenge in home wound care because
it involves not just wound-specific issues but financial and practical considerations. The ideal dressing in the home is one that needs to be changed only every other day, at most. Evidence shows it’s not practical to try to change dressings two or three times daily at home unless the family is providing care.
Develop a checklist
Because the home environment may lack all the resources you need, remembering everything you need to do before you leave the patient’s home may be challenging. To help keep things on track, develop a checklist of reminders that covers these points:
Have necessary medical appointments been arranged? Does the patient have transportation to appointments?
Are there sufficient supplies in the home?
Is there enough medicine? If not, who will pick up the medicine?
Are consults needed, such as social worker or physical therapist?
Who will help with any activities of daily living that the patient is unable to do?
Does the patient with diabetes have a glucometer?
Hours and safety concerns
Typical home wound-care hours are 8:30 a.m. to 4:30 p.m. But realistically, expect variations. For instance, as you’re about to leave, the patient might say, “My wife isn’t feeling well. Could you take her blood pressure?” This means you’ll stay a little longer.
When planning home visits, be aware of safety concerns. If visiting after hours could put you in danger, it’s safer to instruct the patient to call an ambulance and go to the local ED.
Reimbursement
Reimbursement is an important factor in wound care in the home. To be eligible for home care through Medicare, patients must be homebound—meaning they don’t routinely travel to run errands or visit or they’re not able to obtain or receive needed medical services. (With private insurance and workers’ compensation, eligibility requirements may be less restrictive.)
Know that a Medicare patient receives home care as an “episode.” Episodes are 60-day periods; within each 60-day episode, a $592 cap is allotted should a patient require supplies for wound or ostomy care needs. Except for negative-pressure wound therapy, a home care agency can’t bill Medicare for products used; instead, the home-care agency is responsible for the cost of all topical wound-care products and dressings. Agencies may keep patients on service even if they exceed the allowed amount, although patients reaching maximum benefits commonly are discharged from service. Home-care agencies have no choice but to discharge Medicare patients they find aren’t truly homebound.
Also, be aware that Medicare views home health service as an interim service. When a patient is no longer making progress, Medicare expects that the family will provide the patient’s care or the patient will enter a skilled care facility. So it’s important to work hard to obtain good outcomes—not just for the patient but to maintain Medicare reimbursement. Like many private insurance companies, Medicare reimbursement is based on pay for performance; if an agency doesn’t deliver optimal outcomes, it receives lower reimbursement, increasing its financial burden.
A worthwhile option
WCCs use their knowledge and clinical expertise to improve patient outcomes and teach patients, families, and other healthcare team members. They also give the agency recommendations for care and supplies that are evidence based and reflect current best practices in wound care. Accomplishing these goals in a timely fashion under various constraints can be challenging. But if you choose to work in the home, try to keep a smile on your face and joy in your voice for each patient and family. If you like challenges and want a job where you can apply your creativity and function independently, becoming a home-care WCC might be the right choice for you.
Connie Johnson provides wound care in the home and in acute-care settings.
Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild on Wounds (WOW) conference held each September in Las Vegas. Every year, I present the opening session, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.
In the January issue, I discussed some of the updates from my 2015 Buzz Report. Now I’d like to share a few more, along with some of my favorite resources. (more…)
How would you react if you heard a 600-lb patient was being admitted to your unit? Some healthcare professionals would feel anxious—perhaps because they’ve heard bariatric patients are challenging to care for, or they feel unprepared to provide their care. (more…)
Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.
Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management.
By Bill Richlen, PT, WCC, CWS, DWC, and Denise Stetter, PT, WCC, DCCT The Rolling Stones may have said it best when they sang, “You can’t always get what you want,” a sentiment that also applies to wound care. A common frustration among certified wound care clinicians is working with other clinicians who have limited current wound care education and…
By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Welcome to our second annual “Best of the Best” issue of Wound Care Advisor, the official journal of the National Alliance of Wound Care and Ostomy (NAWCO). This may be the first time you have held Wound Care Advisor in your hands because normally we come to you via the Internet.…
Wound photography may motivate patients Having patients view photographs of their wounds can motivate them to become more involved in managing those wounds, according to a study in International Wound Journal, particularly when wounds are in difficult-to-see locations.
Here are a variety of resources you might want to explore. Considering opioid-prescribing practices Healthcare providers’ prescribing patterns for opioids vary considerably by state, according to a report in Vital Signs from the Centers for Disease Control and Prevention (CDC). Here are some facts from the report: • Each day, 46 people die from an overdose of prescription painkillers in…
By Ron Rock MSN, RN, ACNS-BC Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable…
By Nancy Collins, PhD, RD, LD/N, FAPWCA, and Allison Schnitzer Nutrition is a critical factor in the wound healing process, with adequate protein intake essential to the successful healing of a wound. Patients with both chronic and acute wounds, such as postsurgical wounds or pressure ulcers, require an increased amount of protein to ensure complete and timely healing of their…
By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Description The spiral wrap is a technique used for applying compression bandaging. Procedure Here’s how to apply a spiral wrap to the lower leg. Please note that commercial compression wraps come with specific instructions for…
By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Exudate (drainage), a liquid produced by the body in response to tissue damage, is present in wounds as they heal. It consists of fluid that has leaked out of blood vessels and closely resembles blood…
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN Navigating through the thousands of wound care products can be overwhelming and confusing. I suspect that if you checked your supply rooms and treatment carts today, you would find stacks of unused products. You also would probably find that many products were past their expiration dates and that you have duplicate products…
By Jennifer Oakley, BS, RN, WCC, DWC, OMS I used to think I could do it alone. I took the wound care certification course, passed the certification exam, and took all of my new knowledge—and my new WCC credential—back to the long-term care facility where I worked. I was ready to change the world. It didn’t take me long to…
By Kulbir Dhillon, MSN, FNP, APNP, WCC Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic. Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude…
By Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFCN It’s estimated that about 70% of the 1 million ostomates in the United States and Canada will experience or have experienced stomal or peristomal complications. Peristomal complications are more common, although stomal complications (for example, retraction, stenosis, and mucocutaneous separation) can often contribute to peristomal problems by making it difficult to obtain…
The Rolling Stones may have said it best when they sang, “You can’t always get what you want,” a sentiment that also applies to wound care. A common frustration among certified wound care clinicians is working with other clinicians who have limited current wound care education and knowledge. This situation worsens when these clinicians are making treatment recommendations or writing treatment orders not based on current wound-healing principles or standards of care.
Frequently, these same clinicians seem uninterested in listening to what you say and aren’t receptive to treatment suggestions. This is where your skills of diplomacy will make all the difference. Rarely is it a simple matter of sharing your expertise to change a person’s mind. Lack of training and knowledge of current best practices may be part of the reason for resistance. “We’ve always done it that way” or “The rep told me” are common statements you might hear.
Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Have you ever faced responsibility for a patient-care situation you learned about in school but had yet to encounter in the real world? With so many different health conditions and constant advancements in medical care, it’s not surprising that this happens frequently to many clinicians. The first and easiest way for most…
By Joanne Aspiras Jovero, BSEd, BSN, RN; Hussam Al-Nusair, MSc Critical Care, ANP, RN; and Marilou Manarang, BSN, RN A common problem in long-term care facilities, pressure ulcers are linked to prolonged hospitalization, pain, social isolation, sepsis, and death. This article explains how a Middle East rehabilitation facility battles pressure ulcers with the latest evidence-based practices, continual staff education, and…
By Julie Boertje, MS, RN, LMFT, QMRP, and Liz Ferron, MSW, LICSW Almost everyone agrees that achieving a work-life balance is a good thing. Without it, we risk long-term negative effects on our physical and mental health, our relationships, and our work performance. But many clinicians have a hard time achieving this balance due to job demands, erratic work schedules,…
By Bill Richlen, PT, WCC, CWS, DWC, and Denise Stetter, PT, WCC, DCCT The Rolling Stones may have said it best when they sang, “You can’t always get what you want,” a sentiment that also applies to wound care. A common frustration among certified wound care clinicians is working with other clinicians who have limited current wound care education and…
Low BMD common after ostomy Low bone mineral density (BMD) is common in patients with inflammatory bowel disease who have a stoma placed, according to “Frequency, risk factors, and adverse sequelae of bone loss in patients with ostomy for inflammatory bowel diseases,” published in Inflammatory Bowel Diseases.
Take a few minutes to check out this potpourri of resources. International Ostomy Association The International Ostomy Association is an association of regional ostomy associations that is committed to improving the lives of ostomates. Resources on the association’s website include: a variety of discussion groups information for patients list of helpful links. The site also provides contact information for the…
By Ron Rock MSN, RN, ACNS-BC Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable…
By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Exudate (drainage), a liquid produced by the body in response to tissue damage, is present in wounds as they heal. It consists of fluid that has leaked out of blood vessels and closely resembles blood…
By Jennifer Oakley, BS, RN, WCC, DWC, OMS I used to think I could do it alone. I took the wound care certification course, passed the certification exam, and took all of my new knowledge—and my new WCC credential—back to the long-term care facility where I worked. I was ready to change the world. It didn’t take me long to…
By Carrie Carls, BSN, RN, CWOCN, CHRN, and Sherry Clayton, RHIA In an atmosphere of changing reimbursement, it’s important to understand indications and utilization guidelines for healthcare services. Otherwise, facilities won’t receive appropriate reimbursement for provided services. This article focuses on Medicare reimbursement for hyperbaric oxygen therapy (HBOT). (See What is hyperbaric oxygen therapy?) Indications and documentation requirements
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN We’ve all experienced how a bad night’s sleep can affect our mood and ability to function the next day. Now imagine you’re a patient who has a pressure ulcer, most likely secondary to a declining disease state, and you’re being awakened and manipulated every 2 hours or in some cases hourly. How…
Dermatologic difficulties: Skin problems in patients with chronic venous insufficiency and phlebolymphedema By Nancy Chatham, RN, MSN, ANP-BC, CWOCN, CWS; Lori Thomas, MS, OTR/L, CLT-LANA; and Michael Molyneaux, MD
Skin problems associated with chronic venous insufficiency (CVI) and phlebolymphedema are common and often difficult to treat. The CVI cycle of skin and soft tissue injury from chronic disease processes can be unrelenting. If not properly identified and treated, these skin problems can impede the prompt treatment of lymphedema and reduce a patient’s quality of life.
This article reviews skin problems that occur in patients with CVI and phlebolymphedema and discusses the importance of using a multidisciplinary team approach to manage these patients. (more…)
Guidelines for managing prosthetic joint infections released
The Infectious Diseases Society of America has released guidelines for diagnosing and managing prosthetic joint infections.
“Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the Infectious Diseases Society of America,” published in Clinical Infectious Diseases, notes that of the 1 million people each year who have their hips or knees replaced, as many as 20,000 will get an infection in the new joint.
The guidelines describe the best methods for diagnosing these infections, which are not easy to identify. Specifically, infection should be suspected in a patient who has any of the following: persistent wound drainage in the skin over the joint replacement, sudden onset of a painful prosthesis, or ongoing pain after the prosthesis has been implanted, especially if there had been no pain for several years or if there is a history of prior wound healing problems or infections.
Guidelines for treating infections are included and note that 4 to 6 weeks of I.V. or highly bioavailable oral antibiotic therapy is almost always necessary to treat prosthetic joint infections.
A decade of TIME
The TIME acronym (tissue, infection/inflammation, moisture balance, and edge of wound) was first developed more than 10 years ago to provide a framework for a structured approach to wound bed preparation and a basis for optimizing the management of open chronic wounds healing by secondary intention. To mark the event, the International Wound Journal has published “Extending the TIME concept: What have we learned in the past 10 years?”
The review points out four key developments:
• recognition of the importance of biofilms (and the need for a simple diagnostic)
• use of negative-pressure wound therapy
• evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide)
• expanded insight into the role of molecular biological processes in chronic wounds (with emerging diagnostics).
The authors conclude, “The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.”
Bed alarms fail to reduce patient falls
A study in Annals of Internal Medicine found that the use of bed alarms had no statistical or clinical effect on falls in an urban community hospital.
The 18-month trial included 16 nursing units and 27,672 inpatients. There was no difference in fall rates per 1,000 patient-days, the number of patients who fell, or the number of patients physically restrained on units using bed alarms, compared with control units.
Authors of “Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: A cluster randomized trial” speculate the lack of response may be related to “alarm fatigue.”
Drug for HIV might help in Staph infections
A study in Nature reports that the drug maraviroc, used to treat HIV, might be useful for treating Staphylococcus aureus infections.
“CCR5 is a receptor for Staphylococcus aureus leukotoxin ED” found that the CCR5 receptor, which dots the surface of immune T cells, macrophages, and dendritic cells, is critical to the ability of certain strains of Staph to specifically target and kill cells with CCR5, which orchestrate an immune response against the bacteria. One of the toxins the bacterium releases, called LukED, latches on to CCR5 and subsequently punches holes through the membrane of immune cells, causing them to rapidly die.
When researchers treated cells with CCR5 with maraviroc and exposed the cells to the Staph toxin, they found maraviroc blocked toxic effects.
Dog able to sniff out C. difficile
A 2-year-old beagle trained to identify the smell of Clostridium difficile was 100% successful in identifying the bacteria in stool samples, and correctly identified 25 of 30 cases of patients with C. difficile, according to a study in BMJ.
“Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: Proof of principle study” discusses how the dog was trained to detect C. difficile and concludes that although more research is needed, dogs have the potential for screening for C. difficile infection.
After-hours access to providers reduces ED use
Patients who have access to their primary healthcare providers after hours use emergency departments (EDs) less frequently, according to a study in Health Affairs.
“After-hours access to primary care practices linked with lower emergency department use and less unmet medical need” found that 30.4% of patients with after-hours access to their primary care providers reported ED use, compared with 37.7% of those without this access. In addition, those with after-hours access had lower rates of unmet needs (6.1% compared to 12.7%).
The findings come from the 2010 Health Tracking Household Survey of the Center for Studying Health System Change. The total sample included 9,577 respondents.
Neuropathic pain in patients with DPN might contribute to risk of falling
The presence of neuropathic pain in patients with diabetic peripheral neuropathy (DPN) contributes to gait variability, which could in turn contribute to the risk of falling, according to “Increased gait variability in diabetes mellitus patients with neuropathic pain.”
The study, published in the Journal of Diabetes and Its Complications, compared patients with at least moderate neuropathic pain with those who had no pain. Researchers used a portable device to measure gait parameters, such as step length and step velocity.
Amputation rates decrease significantly in patients with PAD
“Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease (PAD): Results from U.S. Medicare 2000–2008” found that amputation rates have decreased significantly, but that significant patient and geographic variations remain.
The study, published in the Journal of the American College of Cardiology, found that among 2,730,742 older patients with identified PAD, the overall rate of lower extremity amputation decreased from 7,258 per 100,000 patients to 5,790 per 100,000. Predictors of lower-extremity amputation included male sex, black race, diabetes mellitus, and renal disease.
