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Clinical Notes

Wound Care Advisor

NPUAP releases new position statement on exposed cartilage as Stage IV ulcer

The National Pressure Ulcer Advisory Panel (NPUAP) has released a new position statement, “Pressure ulcers with exposed cartilage are Stage IV pressure ulcers,” which states that pressure ulcers with exposed cartilage should be classified as Stage IV.
NPUAP notes that although the presence of “visible or palpable cartilage at the base of a pressure ulcer” wasn’t included in Stage IV terminology, cartilage “serves the same anatomical function as bone,” so it fits into the current Stage IV definition, “Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often including undermining and tunneling.”

Medicare expenditures for diabetic foot care varies significantly by region

Medicare spending on patients with diabetes who have foot ulcers and lower extremity amputations varies significantly by region, according to a study in Journal of Diabetes and Its Complications, but more spending doesn’t significantly reduce 1-year mortality.
“Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations” examined data from 682,887 patients with foot ulcers and 151,752 patients with lower extremity amputations.
Macrovascular complications in patients with foot ulcers were associated with higher spending, and these complications in patients with amputations were more common in regions with higher mortality rates.
Rates of hospital admission were associated with higher spending and increased mortality rates for patients with foot ulcers and amputations.
“Geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers and amputations is associated with regional differences in the utilization of inpatient services and the prevalence of macrovascular complications,” the study concludes.

Patients who develop pressure ulcers in hospital more likely to die

Medicare patients who develop pressure ulcers in the hospital are more likely to die during the hospital stay, have longer lengths of stay, and to be readmitted within 30 days after discharge, according to a study of 51,842 patients in the Journal of the American Geriatrics Society.
“Hospital-acquired pressure ulcers: results from the National Medicare Patient Safety Monitoring System Study” found that 4.5% of patients developed at least one new pressure ulcer during their hospitalization. Length of stay averaged 4.8 days for patients who didn’t develop a pressure ulcer, compared to 11.2 days for those with a new pressure ulcer.

Patients with diabetic foot ulcers may have higher risk of death

Patients with diabetes who have foot ulcers have a higher risk of cardiovascular disease and mortality, according to a meta-analysis in Diabetologia.
“The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis” notes that the more frequent occurrence of cardiovascular disease only partly explains the increased mortality rate. Other explanations may include the more advanced stage of diabetes associated with those who had foot ulcers.
A Drugs.com article about the study reported that “analysis of data from more than 17,000 diabetes patients in eight studies found that the more than 3,000 patients with a history of foot ulcers had an extra 58 deaths per 1,000 people each year than those without foot ulcers.”
The study authors emphasize the importance of screening patients with diabetes for foot ulcers so intervention can begin early, as well as lowering cardiovascular risk factors.
Access patient information on foot care from the American Diabetes Association.

Nurse’s innovation for ostomy patients could improve quality of life

An oncology nurse in Australia has developed StomaLife, an alternative to ostomy bags.
StomaLife is a ceramic appliance that eliminates the need for an ostomy bag. According to the StomaLife website, the appliance uses a magnetic implant technology that provides a “pushing force” from within the body outward in order to keep the site intact, while a second part is placed on the stoma site. A cotton gauze pad is used between the skin and the appliance to keep the site separated and to provide air circulation to the surrounding skin.
“The benefits of StomaLife to ostomy patients are continence all day, reduced skin irritation and infection, odour and sound control, leak prevention, waste material flow control and on-demand gas release,” says Saied Sabeti.
StomaLife still needs to be tested and is not yet being produced.

View: StomaLife video

New laser-activated bio-adhesive polymer aims to replace sutures

The Journal of Visualized Experiments, a peer-reviewed video journal, has published “A chitosan based, laser activated thin film surgical adhesive, ‘SurgiLux’: preparation and demonstration.”
SurgiLux is a laser-activated, bio-adhesive polymer that is chitosan-based. Chitosan is a polymer derived from chitin, which is found in fungal cell walls or in exoskeletons of crustaceans and insects. This molecular component allows SurgiLux to form low-energy bonds between the polymer and the desired tissue when it absorbs light.
The technology may be able to replace traditional sutures in the clinical setting. SurgiLux polymer can achieve a uniform seal when activated by a laser and has antimicrobial properties, which help prevent a wound from becoming infected. It also maintains a barrier between the tissue and its surroundings.
SurgiLux has been tested both in vitro and in vivo on a variety of tissues, including nerve, intestine, dura mater, and cornea.

Palliative care raises patient satisfaction and reduces costs

Kaiser Permanente’s home-based palliative care program increased patient satisfaction and decreased emergency department visits, inpatient admissions, and costs, according to an innovation profile in the Agency for Healthcare Research and Quality’s Innovations Exchange.
“In-home palliative care allows more patients to die at home, leading to higher satisfaction and lower acute care utilization and costs” notes that the program uses an interdisciplinary team of providers to manage symptoms and pain, provide emotional and spiritual support, and educate patients and family members on an ongoing basis about changes in the patient’s condition.
Other components of the program include a 24-hour nurse call center, biweekly team meetings, and bereavement services to the family after the patient dies.

More research needed to determine efficacy of maggot debridement therapy

“The efficacy of maggot debridement therapy (MDT)—a review of comparative clinical trials” concludes that “poor quality of the data used for evaluating the efficacy of MDT highlights the need for more and better designed investigations.”
The authors of the article in International Wound Journal reviewed three randomized clinical trials and five nonrandomized clinical trials evaluating the efficacy of sterile Lucilia sericata applied on ulcers.
The studies found that MDT was “significantly more effective than hydrogel or a mixture of conventional therapy modalities, including hydrocolloid, hydrogel and saline moistened gauze,” but the designs of the study were “suboptimal.”

Use tool to select correct antimicrobial dressing

“Ensuring that the correct antimicrobial dressing is selected,” in Wounds International, emphasizes that dressing selection should be based on assessment of the microbial burden in the wound, the wound type, and the location and condition of the wound.
The article includes a checklist that may be helpful for deciding on the level of bacterial burden in a wound. The checklist is used to determine four levels of risk—colonized: at risk; localized infection; spreading infection; and systemic infection. Each level has a corresponding definition.
A table of antimicrobial dressings reviews the antimicrobial agent and dressing form, and the article ends with a case study.

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From the Editor

Wound Care Advisor

The pros and cons of formularies

In health care, we frequently use the terms formulary and protocol interchangeably even though they have different meanings. A formulary is an official list of available dressings, products, and medications. A protocol is a roadmap or guideline on how to use the formulary.

Formularies became popular several years ago when reimbursement changed to bundling and wound-product costs were included in the routine cost of care rather than separately billable. In an effort to control costs, hospitals, home health agencies, and long-term care facilities began exclusive partner agreements with supply and buying groups. (“You use our products exclusively and we’ll give you a huge discount on cost.”)

A good formulary not only can help save money. It can also assist in streamlining care delivery, reducing waste, and directing treatment decisions. But on the flip side, using formularies can have disastrous results. I realized this last week while speaking on the phone with a wound clinician who’d called to ask for wound treatment ideas for a hospice patient. As she described the situation, it became apparent that the patient’s symptoms definitely pointed to high levels of bacteria in the wound. As I began sharing recommendations for treatment ideas, she kept responding: “Nope. Can’t use that, not on our formulary.” “Nope, not on formulary.” The only options available on her hospice formulary were hydrocolloid, hydrogel, or foam dressings, none of which had antibacterial properties.

Providing an appropriate standard of care shouldn’t be dictated by a formulary, and choosing substandard care just because the patient is in hospice isn’t acceptable or appropriate. Evidence-based guidelines, wound characteristics, underlying complications, and patient care goals should dictate management and treatment.

To ensure your formulary is adequate, determine if it includes a variety of product categories, and negotiate the ability to go off formulary if needed. Although cost control is essential, clinicians need access to products and therapies that yield positive outcomes. One size doesn’t fit all in wound care.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois

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How to write effective wound care orders

Wound Care Advisor

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Writing effective orders for wound care is vital to ensure patients receive the right care at the right time, to protect yourself from possible litigation, and to facilitate appropriate reimbursement for clinicians and organizations.
Below are some overall strategies you can use:

  • Avoid “blanket” orders, for example, “continue previous treatment” or “resume treatment at home.” These types of general orders lack the specificity clinicians require to deliver care the patient needs and can be easily misinterpreted. For instance, treatments can change multiple times, and someone could pick a treatment from an incorrect date. (more…)
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Network effectively

Wound Care Advisor

By Joan C. Borgatti, MEd, RN

Sherry stands nervously in the doorway, watching several dozen people chat each other up. The sound of her heartbeat threatens to drown out the conversational din. For the people on the other side of the door, this is a networking event. But for Sherry, it seems like a swap meet of business cards.
If Sherry sounds like you, know that you’re not alone. For many people, networking means an awkward evening spent cradling a wine glass in one hand, thrusting a business card at someone with the other hand, and exchanging small talk.

“Hello. My name is…”

Networking is one of the most overused, misunderstood, and underestimated terms in the business world (and yes, that includes health care). Actually, networking is just a newish term for an activity that has been around for millennia. Savvy people have always seen the wisdom of seeking out others who can help them get ahead.
Simply put, networking is an information exchange, a forum for communicating your needs or agenda and, in return, listening and responding to others’ needs or agendas. Good networking requires emotional reciprocity, which means caring about the needs and agendas of the people you network with. Caring about others’ needs is what nurses do, so networking really shouldn’t be that difficult for a nurse.
Think of networking as a great opportunity to make yourself known, gather critical information, and meet people who can help you now and in the future. Through networking, you can make contacts that further your agenda—whether it’s to find
a mentor, get information on a program you’re interested in, change jobs, or advance from your current position.
Networking isn’t just who you know, but who knows you. If you listen to other networkers and give them the resources they seek (as by introducing them to key people or sharing valuable information), they’ll become grateful—and indebted—networking colleagues.

Set a networking goal

At a networking event, the idea isn’t to meet the greatest number of people possible in one evening. It’s to meet the “right” people—those who can help you realize your goal.
When approaching a networking situation, ask yourself, “What do I want this experience to lead to?” You’ll be much more effective if you have a laser-focused goal. The most successful networker isn’t the one who walks away with the most business cards. It’s the one who leaves with the contacts and information he or she had been seeking.

A tale of two networkers

To demonstrate this point, let’s take the case of two wound care specialists, Myrna and Doris—colleagues who’ve carpooled together to a meeting of their professional organization.
Myrna arrives with an agenda and a plan for the evening: She wants to develop a wound care speakers bureau to boost the community profile of staff at her facility. She seeks out several speakers, who give her valuable tips on how to market her expertise. She also shares her vision of a speakers bureau with attendees from other facilities—and is surprised by the support and tips they offer. She leaves the meeting with valuable information that can further her vision. On the way home, she jots down a reminder to send one of the people she met an article he might find helpful. She also makes notes about what she learned tonight, so she can follow up that week. Clearly, Myrna’s networking has been effective.
Doris, on the other hand, goes to the meeting unfocused. She meanders about the room speaking with a lot of attendees, and exchanges a few business cards. But the “Where-do-you-work?” conversations that ensue provide little insight. Although she enjoys the meeting somewhat, she has accomplished little. That’s understandable, as she set out with no goals. She might have been better off spending the night watching television.

Networking etiquette

To succeed at networking, learn networking etiquette. Rule #1: Turn off your cell phone—or at least put the ringer on vibrate. If you absolutely must take a phone call, discreetly leave the room.
More etiquette advice:
• Wear your name tag on your left lapel so you don’t block your name when shaking hands. If you fill out the name tag yourself, print clearly so your name and title are visible from about 5 feet away. That way, others won’t need to squint at your chest to read your name.
• Keep your handshake firm and friendly. Don’t hang on, and don’t pump! Remember to make eye contact, and smile.
• Keep breath mints handy. Networking usually takes place around drinks and food, and the first thing that greets a new contact shouldn’t be the garlic and onion dip.
• Keep your business cards handy (a business card holder is best), but don’t throw them at everyone you meet. Hand your business card to a contact so it’s right side up and facing that person. When someone hands you a business card, take a moment to look at it; then say thank you and carefully put it away. It’s disrespectful to deface a business card, so don’t write on the back of it.

What happens next?

Okay—you’ve set an agenda, attended the networking event without violating etiquette, and made some good contacts. Now what? This is where many people drop the ball. They fail to follow through on the contacts they make and the information they gain. They simply shove the contacts’ business cards into a Rolodex, where they will sit forgotten.
Instead of letting business cards collect dust, develop a system that helps you follow through with your contacts—whether it’s an electronic tool, a simple calendar notation, or a color-coded filing system. Jot down contact information on each
person you met, along with a summary
of your conversations, when you need to follow up, and so forth. Make the system work for you.
Next, follow through with appropriate communication. Send handwritten thank-you notes to the contacts who gave you valuable information or resources—for instance, those who introduced you to a key player or offered to make a phone call on your behalf. If possible, your note should mention how that information worked out for you. (See Seven steps to effective networking by clicking the PDf icon above.)
In the coming weeks, months, or years, keep these relationships alive and thriving by sending tips or information to each contact. If you see a newspaper article or Internet story about a topic a particular contact was interested in, send it to him or her. This shows you’re thinking about that person, and conveys your generosity and willingness to continue a reciprocal relationship.

Make it happen

Networking opportunities can happen anywhere. Don’t wait for them—create them. Pinpoint your goal, identify the key people who can help make it happen—and then network! It’s as simple as picking up the phone, sending an e-mail, or meeting over lunch. With a little effort, networking can be an enjoyable and valuable career resource.

Selected references
Ames G. Follow-up after the networking meeting and job interview. www.garyames.net/5-followupaftermeet.htm. Accessed August 15, 2012.

Wiklund P. Follow up: key to networking success. Approved Articles Website. www.approvedarticles.com/Article/Follow-up—Key-to-Networking-Success/5022. Accessed August 15, 2012.

Joan C. Borgatti, MEd, RN, is the owner of Borgatti Communications in Wellesley Hills, Mass., which provides writing, editing, and coaching services. You may e-mail her at [email protected].

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Clinician Resources

Wound Care Advisor

Here are a variety of resources related to quality that wound care clinicians may find valuable.

Home Health Quality Improvement National Campaign

If you are interested in home care, you’ll want to visit The Home Health Quality Improvement (HHQI) National Campaign’s website. HHQI is a grassroots project of the Centers for Medicare & Medicaid Services designed “to unite home health stakeholders and multiple health care settings under the shared vision of reducing avoidable hospitalizations and improving medication management.”
The many available free resources on the campaign’s website include:
•    webinars; for example, “Hospital Readmissions and the Role of Home Care”
•    best practice innovation packages, including ones on medication management and fall prevention.

You must register to obtain some of the resources.

◊   http://www.homehealthquality.org/hh/default.aspx

Reducing Avoidable Readmissions Effectively

Reducing Avoidable Readmissions Effectively (RARE) is a campaign in Minnesota that is working with hospitals and care providers to prevent hospital readmissions within 30 days of discharge.
Even if you aren’t in Minnesota, you can access resources such as a webinars. Past webinars include “Involving Patients and Families in Reducing Avoidable Readmissions” and “Home Care and Reducing Hospital Readmissions.”
You can also download “Recommended Actions for Improved Transitions,” which covers five key areas: patient and family engagement and activation, medication management, comprehensive transition planning, care transition support, and transition communication.

◊   http://rarereadmissions.org/resources/RARE_Report_2012_06.html

TeamSTEPPS®

Effective communication is essential for any quality initiative to be successful. TeamSTEPPS is a teamwork system that improves communication through train-ing and tools. The Agency for Healthcare Research and Quality and the Defense Department have teamed up to provide
resources for implementing Team STEPPS.
Tools include:
•    Core TeamSTEPPS Training Curriculum Materials
•    TeamSTEPPS Rapid Response Systems (RRS) Training Module
•    TeamSTEPPS Teamwork Perception Questionnaire
•    Pocket Guide that summarizes TeamSTEPPS principles in a portable, easy-
to-use format.

The educational materials contain information that clinicians can integrate into their practice. Video vignettes illustrate how failures in teamwork and communication can place patients in jeopardy and how successful teams can work to improve patient outcomes.
You can order free TeamSTEPPS materials, which are available online.

◊   http://teamstepps.ahrq.gov

Institute for Healthcare Improvement

The Institute for Healthcare Improvement is an independent, not-for-profit organization that focuses on testing new models of care, disseminating best practices, and building the will to change to improve health care.
Among the many resources on the website:
•    tools such as “Self-Management Toolkit for People with Chronic Conditions and Their Families”
•    useful publications
•    white papers such as “Using Care
Bundles to Improve Health Care
Quality”
•    case studies of successful strategies
•    audio and video broadcasts
•    links to other helpful websites.

Registration is free.

◊   http://www.ihi.org/Pages/default.aspx   

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Foam dressing

Wound Care Advisor

By Nancy Morgan, MBA, BSN, RN, WOC, WCC, CWCMS, DWC

Each month, Apple Bites brings you a tool you can apply in your daily practice.

Description

•    Semipermeable polyurethane foam dressing
•    Nonadherent and nonlinting
•    Hydrophobic or waterproof outer layer
•    Provides moist wound environment
•    Permeable to water vapor but blocks entry of bacteria and contaminants
•    Available in various thicknesses with or without adhesive borders
•    Available in pads, sheets, and cavity dressings (more…)

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“Ouch! That hurts!”

Wound Care Advisor

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Wound pain can have a profound effect on a person’s life and is one of the most devastating aspects of living with a wound. In addition to pharmaceutical options, wound care clinicians should consider other key aspects of care that can alleviate pain. Here is a checklist to ensure you are thorough in your assessment. (more…)

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Clinical Notes

Wound Care Advisor

New wound-swabbing technique detects more bacteria

The new Essen Rotary swabbing technique takes a few seconds longer to perform than traditional techniques, but improves bacterial count accuracy in patients with chronic leg ulcers, according to a study published by Wounds International.
“Evaluation of the Essen Rotary as a new technique for bacterial swabs: Results of a prospective controlled clinical investigation in 50 patients with chronic leg ulcers” reports that Essen Rotary detected significantly more bacteria compared to standard techniques and was the only one to identify five patients with methicillin-resistant Staphylococcus aureus (MRSA), compared to three detected by other techniques.
The Essen Rotary technique samples a larger surface area of the wound, which is beneficial for detecting MRSA.
“The Essen Rotary may become the new gold standard in routinely taken bacteriological swabs especially for MRSA screenings in patients with chronic leg ulcers,” the study authors write.

Reducing HbA1c by less than 1% cuts cardiovascular risk by 45% in patients with type 2 diabetes

A study presented at the American Diabetes Association 72nd Scientific Sessions found lowering HbA1c an average of 0.8% (from a mean of 7.8% to 7.0%, the treatment target) reduced the risk of cardiovascular death by 45% in patients with type
2 diabetes.
The absolute risk of mortality from a cardiovascular event was 9.9 events per 1,000 person-years in patients with decreasing HbA1c compared to 17.8 events in patients with stable or increasing HbA1c.
“HbA1c reduction and risk of cardiovascular diseases in type 2 diabetes: An observational study from the Swedish NDR” examined data from 18,035 patients in the Swedish National Diabetes Register.

CMS revises hospital, nursing home comparison websites

The Centers for Medicare & Medicaid Services (CMS) has enhanced two websites designed to help the public make informed choices about their health care.
Hospital Compare and Nursing Home Compare now have better navigation and new comparison tools. The two sites include data on quality measures, such as frequency of hospital-acquired infections, and allow the user to compare hospitals on these measures.
Improvements include easy-to-use maps for locating hospitals, a new search function that enables the user to input the name of a hospital, and glossaries that are easier to understand. It’s now also possible to access the data on the sites through mobile applications.
CMS maintains the websites, which are helpful for anyone who wants to compare facilities, not just patients on Medicare or Medicaid.
For more information, read the article in Healthcare IT News.

IOM releases report on accelerating new drug and diagnostics development

The Institute of Medicine (IOM) released “Accelerating the development of new drugs and diagnostics: Maximizing the impact of the Cures Acceleration Network—Workshop Summary.” The report is a summary of a forum that brought together members of federal government agencies, the private sector, academia, and advocacy groups to explore options and opportunities in the implementation of Cures Acceleration Network (CAN). The newly developed CAN has the potential to stimulate widespread changes in the National Institutes of Health and drug development in general.

Focus on individualized care—not just reducing swelling—in lymphedema patients

As a result of two extensive literature reviews, a researcher at the University of Missouri found that emphasizing quality of life—not just reducing swelling—is important for patients with lymphedema. Many providers and insurance companies base treatment on the degree of edema, but the volume of fluid doesn’t always correspond with the patients’ discomfort. Instead, an individualized plan of care should be developed.
The researchers found that Complete Decongestive Therapy (CDT), a comprehensive approach for treating lymphedema that includes skin and nail care, exercise, manual lymphatic drainage, and compression, may be the best form of specialized lymphedema management. For more information about CDT, watch for the November/December issue of Wound Care Advisor.

Plague case in Oregon draws national attention

An article about a case of the plague in Oregon has appeared on Huffington Post. A welder contracted the disease as a result of unsuccessfully removing a mouse from a stray cat’s mouth. Part of his hands have, in the words of the article, “darkened to the color of charcoal.” Later tests confirmed the cat had the plague.
Plague cases are rare in the United States. According to the Centers for Disease Control and Prevention, an average of 7 human cases are reported each year, with a range of 1 to 17 cases. Antibiotics have significantly reduced morality. About half of cases occur in people ages 12 to 45.

Use of negative pressure wound therapy with skin grafts

“Optimal use of negative pressure wound therapy for skin grafts,” published by International Wound Journal, reviews expert opinion and scientific evidence related to the use of negative pressure wound therapy with reticulated open-cell foam for securing split-thickness skin grafts.
The article covers wound preparation, treatment criteria and goals, economic value, and case studies. The authors conclude that the therapy has many benefits, but note that future studies are needed “to better measure the expanding treatment goals associated with graft care, including increased patient satisfaction, increased patience compliance and improved clinical outcomes.”

Mechanism for halting healing of venous ulcers identified

Researchers have identified that aberrantly expressed microRNAs inhibit healing of chronic venous ulcers, according to a study in The Journal of Biological Chemistry.
Six microRNAs were plentiful in 10 patients with chronic venous ulcers. The microRNAs target genes important in healing the ulcers. In an article about the study, one of the researchers said, “The more we know about the molecular mechanisms that contribute to [the development of venous ulcers], the more we can rationally develop both diagnostic tools and new therapies.”

Hemodialysis-related foot ulcers not limited to patients with diabetes

Both patients with diabetes and those without are at risk for hemodialysis-related foot ulcers, according to a study published by International Wound Journal.
Researchers assessed 57 patients for ulcer risk factors (peripheral neuropathy, peripheral arterial disease, and foot pathology, such as claw toes, hallux valgus, promi­nent metatarsal heads, corns, callosities, and nail pathologies) at baseline, and noted mortality 3 years later.
In all, 79% of patients had foot pathology at baseline, and 18% of patients without diabetes had peripheral neuropathy. Peripheral arterial disease was present in 45% of diabetic and 30% of nondiabetic patients. Nearly half (49%) of patients had two or more risk factors. Only 12% of patients had no risk factors. The presence of peripheral arterial disease and peripheral neuropathy increased risk of mortality.
The authors of “Prevalence of risk factors for foot ulceration in a general haemodialysis population” state that the high prevalence of risk factors in nondiabetic patients indicates that they are at risk for developing foot ulcers.

Study identifies risk factors for mortality from MRSA bacteremia

A study in Emerging Infectious Diseases found that older age, living in a nursing home, severe bacteremia, and organ impairment increase the risk of death from methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.
Consultation with a specialist in infectious disease lowers the risk of death, and MRSA strain types weren’t associated with mortality.
“Predicting risk for death from MRSA bacteremia” studied 699 incidents of blood infection from 603 patients who had MRSA bacteremia.

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