About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders.
A stoma has no sensory nerve endings and is insensitive to pain. Yet several complications can affect it, making accurate assessment crucial. These complications may occur during the immediate postoperative period, within 30 days after surgery, or later. Lifelong assessment by a healthcare provider with knowledge of ostomy surgeries and complications is important.
Critical limb ischemia may not increase mortality risk in patients with diabetes Diabetic patients with critical limb ischemia (CLI) who are assessed quickly and treated aggressively do not have an increased risk of long-term cardiac mortality, according to a study in Diabetes Care.
By Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis…
By T. Michael Britton, RN, NHA, WCC, DWC As wound care professionals, we’ve all experienced a time when we felt that our patient didn’t have the appropriate wound treatment orders. However, the physician, nurse practitioner, or other prescriber wouldn’t follow your recommendation. This situation is not only frustrating but can delay the healing process. This article explores why a prescriber…
by Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS What an honor it is to be the wound care “superhero”—the guru, the healer, the go-to person. Unfortunately, this honor may be accompanied by wound care overload—too much to do in too little time. Once someone is crowned the superhero specialist, others may try to transfer every aspect of wound and…
By Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, OMS; and Judith LaDonna Burns, LPN, WCC, DFC About 1 million people in the United States have either temporary or permanent stomas. A stoma is created surgically to divert fecal material or urine in patients with GI or urinary tract diseases or disorders. A stoma has no sensory nerve endings and…
By Robyn Bjork, MPT, CWS, WCC, CLT-LANA The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of…
By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Knowledge is exploding online, making it essential that you’re comfortable using the Internet. You can also go online to save time and find a job, among other tasks. (See Online value.) However, you also need to keep in mind that anyone can put information on the Internet. As the caption of…
Study finds less-invasive method for identifying osteomyelitis is effective
Researchers have found that using hybrid 67Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging combined with a bedside percutaneous bone puncture in patients with a positive scan is “accurate and safe” for diagnosing osteomyelitis in patients with diabetes who have a foot ulcer without signs of soft-tissue infection.
The new method, which avoids an invasive bone biopsy, has a sensitivity of 88% and a specificity of 93.6%. In the study of 55 patients, antibiotic treatment was avoided in 55% of suspected cases.
MRSA strains will likely continue to coexist in hospitals and communities
The strains of methicillin-resistant Staphylococcus aureus (MRSA) differ in the hospital and community settings, and both are likely to coexist in the future, according to a study in PLOS Pathogens.
C. difficile prevention actions fail to stop spread
Despite increasing activities to prevent the spread of Clostridium difficile, infection from C. difficile remains a problem in healthcare facilities, according to a survey of infection preventionists by the Association for Professionals in Infection Control and Epidemiology (APIC).
The survey found that 70% of preventionists have adopted additional interventions in their healthcare facilities since March 2010, but only 42% have seen a decline in C. difficile infection rates; 43% saw no decline.
A total of 1,087 APIC members completed the survey in January 2013. The survey also found that more than 92% of respondents have increased emphasis on environmental cleaning and equipment decontamination practices, but 64% said they rely on observation, rather than more accurate and reliable monitoring technologies, to assess cleaning effectiveness.
In addition, 60% of respondents have antimicrobial stewardship programs at their facilities, compared with 52% in 2010. Such programs promote the appropriate use of antibiotics, which can help reduce the risk of C. difficile infection.
Mast cells may not play significant role in wound healing
“Evidence that mast cells are not required for healing of splinted cutaneous excisional wounds in mice,” published in PLOS One, analyzed wound healing in three types of genetically mast-deficient mice and found they reepithelialized their wounds at rates similar to control mice. At the time of closure, the researchers found that scars in all the mice groups were similar in both “quality of collagen deposition and maturity of collagen fibers.” The findings fail to support the previously held belief that mast cells are important in wound healing.
Study identifies effective casting for diabetes-related plantar foot ulcers
Nonremovable casts that relieve pressure are more effective than removable casts or dressings alone for the treatment of plantar foot ulcers caused by diabetes, according to an analysis of clinical trials.
The authors of “Pressure-relieving interventions for treating diabetic foot ulcers,” published by The Cochrane Library, reviewed 14 randomized clinical trials that included 709 participants. Nonremovable pressure-relieving casts were compared to dressings alone, temporary therapeutic shoes, removable pressure-relieving devices, and surgical lengthening of the Achilles tendon.
The study also notes that when combined with Achilles tendon lengthening, nonremovable devices were more successful in one forefoot ulcer study than the use of a nonremovable cast alone.
Most studies were from the United States (five) and Italy (five), with Germany, the Netherlands, Australia, and India each contributing one study.
Prescriber preference drives use of antibiotics in long-term care
The study of 66,901 patients from 630 long-term care facilities found that 77.8%
received a course of antibiotics. The most common length (41%) was 7 days, but the length exceeded 7 days in 44.9% of patients. Patient characteristics were similar among short-, average-, and long-duration prescribers.
The study authors conclude: “Future trials should evaluate antibiotic stewardship interventions targeting prescriber preferences to systematically shorten average treatment durations to reduce the complications, costs, and resistance associated with antibiotic overuse.”
Electrophysical therapy may be helpful for diabetic foot ulcers
The authors of the study in International Wound Journal reviewed eight trials with a combined total of 325 patients. Five studies were on electrical stimulation, two on phototherapy, and one on ultrasound. Because of the small number of trials, the possibility of harmful effects can’t be ruled out, and the authors recommend “high-quality trials with larger sample sizes.”
Significant geographic variations in spending, mortality exist for diabetic patients with foot ulcers and amputations
The study in Journal of Diabetes and Its Complications found that higher spending wasn’t associated with a significant reduction in 1-year patient mortality. In addition, rates of hospital admission were associated with higher per capita spending and higher mortality rates for patients.
Home-based exercise program improves life for lymphedema patients
An individualized, home-based progressive resistance exercise program improves upper-limb volume and circumference and quality of life in postmastectomy patients with lymphedema, according to a study published in the Journal of Rehabilitation Research and Development.
The guidelines include recommendations for practice, education, policy, and future resource. Strategies for implementation are given, as well as several useful appendices, such as:
• Debridement Decision-Making Algorithm
• A Guide to Dressing Foot Wounds
• PEDIS: Diabetes Foot Ulcer Classification System
• Offloading Devices
• Optimal Treatment Modalities.
PREPARE is a useful and patient-friendly website designed to help prepare people to make complex medical decisions. The website was developed by clinical researchers from the San Francisco VA Medical Center; the University of California, San Francisco; and NCIRE—The Veterans Health Research Institute.
PREPARE uses videos to provide concrete examples of how to identify what is most important in life; how to communicate that with family, friends, and doctors; and how to make informed medical decisions when the time comes. Users can also download a PDF of a PREPARE pamphlet.
Free guides for infection prevention from APIC
Download two free implementation guides for infection prevention from the Association for Professionals in Infection Control and Epidemiology (APIC):
This revised guide contains strategies for prevention, considerations for specific patient populations, evolving practices, and how to incorporate current regulations.
Topics include:
• C. difficile in pediatrics and skilled nursing facilities
• pathogenesis and changing epidemiology of C. difficile infection diagnosis
• environmental control
• new and emerging technologies
• tools and examples to help apply preventative measures, such as hand hygiene monitoring, environmental cleaning, and isolation compliance.
This guide includes infection-prevention standards, regulations, and best practices, as well as instructions, examples, and tools to conduct surveillance and risk assessments.
One of the worst fears of a wound care clinician is inadvertently compressing a leg with critical limb ischemia—a condition marked by barely enough blood flow to sustain tissue life. Compression (as well as infection or injury) could lead to necrosis, the need for amputation, or even death. The gold standard of practice is to obtain an ankle-brachial index (ABI) before applying compression. However, recent research and expert opinion indicate an elevated or normal ABI is deceptive in patients with advanced diabetes. What’s worse, in the diabetic foot, skin may die from chronic capillary ischemia even when total blood perfusion is normal. For information on how to perform an ABI and interpret results, click on this link. (more…)
As clinicians, we’re proud of the expert care we provide patients. But we also know that just doing our job isn’t enough to advance our careers. Mastering good communication skills is essential for all clinicians at all career stages—especially with today’s flatter organizational structures and more participatory management styles. Knowing how to communicate in a professional manner can give you the edge you need for career advancement.
Opportunity rarely knocks any more. Instead it may present as a phone call, voice mail, e-mail, or text message. Be sure to use proper etiquette with all communication forms.
Speaking with managers
When dealing with your manager, use a solution-focused approach. Don’t be a complainer. Some communication experts point out that people complain about things they can do something about—not things they have no power over. For example, they don’t complain about their foot size because there’s nothing they can do about it. Yet people often complain about their jobs because they’re unwilling to take the risk of making a change.
We need to take charge of our lives. We can accept the fact—without complaining—that we’re making the choice to stay where we are. Or we can make a request or take action to achieve a desired outcome. Suppose you work on a clinical unit and disagree with the way your manager makes clinical assignments. You have several options:
Complain to coworkers and make the workplace miserable for others.
Speak with your manager and make suggestions for improvement.
Leave your job and go elsewhere if you can’t work with your manager to make things better.
If you decide to stay in your job, accept the fact that you’ve made that choice. Take responsibility for it and stop complaining.
Speaking on the phone with physicians
For clinicians who are not physicians, the key to effective communication with physicians is to remember you’re an important member of the healthcare team. An effective way to guide your communication with physicians and other colleagues is to use a tool such as SBAR (Situation, Background, Assessment, Recommendation). Say, for instance, you want to suggest the doctor order an anxiolytic for your patient. Here’s how you might do it using SBAR:
Situation: “Mrs. Smith is complaining of severe anxiety.” Background: “She is 1 day post-op from a lumbar laminectomy.” Assessment: “She is alert and oriented and her vital signs are stable. She has no numbness or tingling in her extremities.” Recommendation: “She said she takes lorazepam 2 mg orally at when she’s anxious. Would you like to order something for her?”
Before ending the conversation, repeat and clarify the medication order (if the doctor gives one).
Telephone
The sound of your voice and your manners are essential components of phone etiquette. Smile—the smile on your face comes through in your voice. Here are five more tips:
Get yourself organized before placing the call.
Minimize background noise.
Immediately identify yourself. Don’t assume the recipient will recognize your voice.
Concentrate on listening and avoid multitasking.
Schedule phone conversations to avoid playing phone tag.
Voice mail
Voice mail is an efficient way to communicate. Again, five tips:
Always be prepared to leave a message. Jot down your key message points before you call, to avoid stuttering and stammering.
Be concise and to the point.
State your name and the date, time, and purpose of your call.
Enunciate clearly and speak slowly.
State your name and phone number twice at the end of the message so the recipient doesn’t need to replay your message.
E-mail
In many business settings, e-mail has almost replaced letters and memos. In many cases, an e-mail is a recipient’s first impression of you, so follow these tips:
Make the subject line specific. This helps the reader prioritize the message and file it for easy retrieval.
Use a greeting and a close. It’s more polite and less impersonal.
Keep your message concise.
Keep your tone polite and businesslike.
Use your e-mail signature function, which provides several ways to contact you.
Text messages
This form of communication can be the most challenging and unpredictable. Some people send text messages routinely, while others may be unfamiliar with this method. You can’t go too far wrong if you take this advice:
Get to the point quickly. No one wants to read a long message on a mobile phone.
Don’t text during meetings. It’s rude to do so, and others can hear you clicking away or see the light from your screen.
Consider the recipient before using text abbreviations. Some people may not understand text lingo.
Consider the time when sending a text. Although you may be awake at 5 a.m., the sound of your incoming message might disturb a sleeping recipient.
Don’t expect an immediate response to your text. If the message is time sensitive, pick up the phone instead.
Improving the way we speak with managers and physicians can go a long way toward career advancement and professional satisfaction. Common courtesy is just as essential in e-mail, voice mail, and text messages as in face-to-face communication. When you follow the guidelines I’ve given, you’ll elevate your professional communications a few notches.
Selected references
Canfield J, Switzer J. The Success Principles: How to Get from Where You Are to Where You Want to Be. New York, NY: Morrow; 2006.
Kramer M, Schmalenberg, C. Confirmation of a healthy work environment. Crit Care Nurse. 2008 Apr;28(2):56-63.
Pagana K. The Nurse’s Communication Advantage: How Business Savvy Communication Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2011.
Pagana K. The Nurse’s Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2008.
A keynote speaker, Kathleen D. Pagana is a professor emeritus at Lycoming College in Williamsport, Pennsylvania, and president of Pagana Keynotes and Presentations. She is the author of The Nurse’s Communication Advantage and The Nurse’s Etiquette Advantage. To contact her, visit www.KathleenPagana.com.
Here are resources that can help you in your busy clinical practice by giving you information quickly.
Pressure ulcer resources
Instead of searching through Google or another search engine for pressure ulcer resources, start with this comprehensive list on the Centers for Medicare & Medicaid Services website.
Examples of resources included are:
“Preventing pressure ulcers in hospitals: A toolkit for improving quality of care.” This toolkit from the Agency for Healthcare Research and Quality (AHRQ) is designed to help hospitals in implementing pressure ulcer prevention strategies.
“On-time pressure ulcer healing project.” Another AHRQ initiative, this resource is designed for those working in long-term care facilities.
“Pressure ulcer prevention.” This table from the Institute for Healthcare Improvement lists possible mentors you can work with in the area of ulcer prevention.
“Shawnee Medical Center wound care quick reference guide.” This is a handy one-page reference guide that includes photographs and recommendations.
“How-to guide: Prevent pressure ulcers—pediatric supplement.” This guide, tailored for pediatrics, describes key evidence-based care components for preventing pressure ulcers and describes how to implement these interventions.
You can also access case studies from a variety of facilities around the United States.
The National Lymphedema Network is a nonprofit organization founded in 1988 to provide education and other information to healthcare professionals and patients with lymphedema, as well as the general public. The site includes an explanation of lymphedema that may be helpful for you to use in teaching your patients. It also includes access to some of the articles from the newsletter LymphLink.
Many patients with chronic wounds have diabetes. To ensure those patients receive the best possible care, you can refer to the 2013 Standards of Medical Care in Diabetes from the American Diabetes Association, which were published in the January issue of Diabetes Care.
The journal provides a summary of the revisions and an executive summary of the standards related to each area, including diagnosis, testing, prevention, monitoring, and pharmacologic and nonpharmacologic management.
The guidelines include valuable information related to neuropathy screening and treatment and foot care. Recommendations for foot care include performing an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.
An Unna boot is a special dressing of inelastic gauze impregnated with zinc, glycerin, or calamine that becomes rigid when it dries. It is used for managing venous leg ulcers and lymphedema in patients who are ambulatory. When the patient walks, the rigid dressing restricts outward movement of the calf muscle, which directs the contraction force inward and improves the calf-muscle pumping action, thereby improving venous flow. An Unna boot does not provide compression and is contraindicated for arterial insufficiency. (more…)
The number of people with diabetes who are meeting the ABC goals—hemoglobin A1C, blood pressure, and LDL cholesterol—has risen significantly in recent years, according to a study published by Diabetes Care. Patients meeting all three goals rose from about 2% in 1988 to about 19% in 2010.
Gains were made in each of the ABC goals, based on 2007 to 2010 data: 53% of patients met A1C goals, compared to 43% in 1988 to 1994 data; 51% met blood pressure goals, compared to 33%; and 56% met LDL goals, compared to 10%.
Younger people were less likely to meet A1C and cholesterol goals. Compared with non-
Hispanic whites, Mexican Americans were less likely to meet A1C and LDL goals and non-Hispanic blacks were less likely to meet blood pressure and LDL goals.
The researchers analyzed data from the National Health and Nutrition Examination Surveys from 1988–1994, 1999–2002, 2003–2006, and 2007–2010. Nearly 5,000 people age 20 or older participated.
Although progress had been made, the researchers conclude, “Despite significant improvement during the past decade, achieving the ABC goals remains suboptimal among adults with diabetes, particularly in some minority groups.”
Daily bathing with chlorhexidine-impregnated washcloths reduces infection risk
A study in The New England Journal of Medicine reports that daily bathing with chlorhexidine-impregnated washcloths reduces the risk of becoming infected with multidrug-resistant organisms and subsequent development of hospital-acquired bloodstream infections in intensive care unit patients.
“Effect of daily chlorhexidine bathing on hospital-acquired infection” included 7,727 patients in nine intensive care and bone marrow units in six hospitals. The units were randomly assigned to bathe patients with either no-rinse 2% chlorhexidine-impregnated washcloths or nonantimicrobial washcloths for 6 months; then, the units switched to the opposite product for 6 months.
The rate of infection with multidrug-resistant organisms was 23% lower in the chlorhexidine group and the rate of hospital-acquired bloodstream infection was 28% lower in the chlorhexidine group.
Patients tend not to wear custom-made footwear for preventing diabetic foot ulcers
Adherence to wearing prescription custom-made footwear was low among patients with diabetes, neuropathy, and a recently healed plantar foot ulcer, according to a study in Diabetes Care. The low adherence was particularly notable at home, where patients did the most walking.
Factors associated with higher adherence included lower body mass index, more severe foot deformity, and more appealing footwear.
Tedizolid works as well as linezolid in patients with acute bacterial skin infections
A JAMA study says that a 200-mg once-daily dose of oral tedizolid phosphate over 6 days was as effective as 600 mg of oral linezolid every 12 hours for 10 days in patients with acute bacterial skin and skin-structure infections, including cellulitis or erysipelas, major cutaneous abscesses, and wound infections.
A shorter course of tedizolid may be a “reasonable alternative” to linezolid for treating acute bacterial skin and skin-structure infections, the study concludes.
Water-based exercise improves ROM in patients with long-term arm lymphedema
A study of breast cancer survivors (median 10 years after surgery) with lymphedema found that a water-based exercise program improved shoulder range of motion (ROM).
The program consisted of at least twice-weekly water-based exercise for 8 weeks. At first, participants were supervised, but later they exercised independently. Although lymphedema status didn’t change, those who performed water-based exercise had an increase in ROM, showing improvement years after surgery.
Dehydrated amniotic membrane allograft possible option for treating chronic wounds
A dehydrated amniotic membrane allograft (EpiFix) was used to treat four patients whose wounds hadn’t closed after conservative and advanced measures and who had been referred for plastic procedures. A variety of wounds healed (located on the elbow, knee, hand, and ankle) after one to three applications of the amniotic material, which patients tolerated well. The wounds remained closed several months later.
Study casts doubt on MLD’s role in breast cancer–related lymphedema
A meta-analysis published in the World Journal of Surgical Oncology found the “current evidence” from randomized clinical trials “does not support” the use of manual lymphatic drainage (MLD) in preventing or treating lymphedema in patients with breast cancer.
The authors analyzed 10 randomized clinical trials with 566 patients.
CDC issues additional prevention steps for carbapenem-resistant Enterobacteriaceae
On Feb. 14, the Centers for Disease Control and Prevention (CDC) issued additional prevention steps for carbapenem-resistant Enterobacteriaceae (CRE). Increased reports of CRE prompted the action: Of the 37 unusual forms of CRE reported in the U.S., the last 15 have been reported since July 2012.
• When a CRE is identified in a patient with a history of an overnight stay in a healthcare facility (within the last 6 months) outside the U.S., send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism.
• For patients admitted to healthcare facilities in the U.S. after recently being hospitalized (within the last 6 months) in countries outside the U.S., consider performing rectal screening cultures to detect CRE colonization, and place patients on contact precautions while awaiting the results.
Examples of Enterobacteriaceae include Klebsiella species and Escherichia coli. CRE are Enterobacteriaceae with high levels of resistance to antibiotics, including carbapenems. CRE infections most commonly occur among patients who are receiving antibiotics and significant medical treatment for other conditions.
Clinical practice guidelines help ensure we are applying the latest knowledge and expertise when we’re caring for patients. Here are a few recent guidelines that you may find useful.
Measurement of ankle-brachial index
An American Heart Association scientific statement, “Measurement and interpretation of the ankle-brachial index (ABI),” published in Circulation, outlines the use of ABI, terminology, how to calculate the value, training, standards, and suggestions for future research.
Recommendations for obtaining an ABI measurement include:
• Use the Doppler method to determine the systolic blood pressure in each arm and each ankle.
• Use the appropriate cuff size, with a width of at least 40% of the limb circumference.
• Place the ankle cuff just above the malleoli with the straight wrapping method.
• Cover open lesions with the potential for contamination with an impermeable dressing.
• Avoid using a cuff over a distal bypass.
The article also recommends measurement and interpretation of ABI be part of the standard curriculum for nursing and medical students. For more information about ABI, read “Bedside ankle-brachial index testing: Time-saving tips” in this issue of Wound Care Advisor.
Childhood obesity continues to be a significant problem in the United States, requiring innovative approaches for prevention and management. Those who are obese run the risk of poorer wound healing.
“Approaches to the prevention and management of childhood obesity: The role of social networks and the use of social media and related electronic technologies: A scientific statement from the American Heart Association,” published in Circulation, evaluates the role of social networks and social media in relation to childhood obesity and presents five steps for using social networks: 1 Define the goal of the intervention. 2 Identify the social network. 3 Develop and pilot test the intervention. 4 Implement the intervention. 5 Spread the intervention.
The guidelines conclude that social media holds promise as a tool, but more research is needed.
Guidelines for managing patients with stable ischemic heart disease
Many patients with wound or ostomy needs have comorbid heart disease. Be sure you are aware of the most current information for managing these patients by accessing “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease,” published in Circulation.
The guidelines acknowledge the vital importance of shared decision making between the healthcare provider and the patient. The information is divided into four sections with supporting algorithms:
• approaches to diagnosis
• risk assessment
• treatment
• follow-up.
Access the top 10 things to know and the executive summary.
In each case, the synthesis includes information in the following categories:
• areas of agreement and difference
• comparison of recommendations
• strength of evidence and recommendation grading schemes
• methodology
• source(s) of funding
• benefits and harms
• abbreviations
• status.
Access these and other guideline syntheses from AHRQ.
Bonus resource: Ethical case study of a patient refusing skin ulcer treatment
Free, one-time registration is required to view the entire video and all other
content on the Medscape website.
Patients have a right to make their own decisions, but what happens when a decision is so painful for staff that it affects morale? Arthur Caplan, PhD, Division of Medical Ethics at the NYU Langone Medical Center in New York, discusses such a case: “Patients have the right to choose death from bedsores.”
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.
January is traditionally the time of year when everyone starts the New Year fresh with resolutions for change—better organization, healthy living, new beginnings. This year, I want to challenge you to include your patients in your resolution planning. Work with each patient and come up with ideas to help improve their quality of life by, for instance, healing a wound, wearing a splint, keeping blood glucose levels within normal range, elevating the feet.
For resolutions to be effective, a “buy in” must exist. Most people don’t like
being told what they must do and would rather hear what they can do. So be sure to include your patients in the planning process. Ask them their opinion. Ask “What could I do differently to help you with this?” Determine if their treatments could be interfering with their lifestyle. Set mutually compatible goals. Most of all, help promote patients’ search for their own solutions.
To make an informed choice of can do instead of must do, patients must have a clear understanding of the facts, implications, and consequences. The Institute of Medicine defines health literacy as the degree to which individuals have the capacity to understand, obtain, and process basic health information needed to make appropriate health decisions. It’s easy to assume our patients know all the facts, especially if they have had the wound, ostomy, or diagnosis for many years. However, according to the 2003 National Assessment of Adult Literacy, almost 45% of the U.S. population (about 93 million Americans) have, at best, only basic health literacy skills.
To improve their health literacy, review your patients’ understanding of their situation and ask them to describe their diagnosis and treatment plan in their own words. If they can’t describe these correctly, reteach the information. Consider the possibility that you might have to use a new educational approach or method.
A new year and a new start, with a shared understanding of problems and potential solutions between the patient and wound care team can get you started on the pathway to success. To quote Zig Ziglar, “A goal properly set is halfway reached.”
Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois
