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CAWC Abstracts
Clinical Practice Abstracts
An interdisciplinary team approach using botulinum toxin type A* to reduce the effects of spasticity on positioning and risk of skin
Jablonski L, PT; Carewest; Plamondon S, MD, FRCP(C), CSCN (EMG) Assistant Professor Physiatry, Department of Neuroscience, University of Calgary; Juchymenko J, OT, Carewest; Calgary, Alberta
Objective: To evaluate through an interdisciplinary team approach targeted botulinum toxin type a* (BTX-A) injections to manage spasticity interfering with positioning in select continuing care centre residents, and effectiveness as an intervention to prevent skin breakdown.
Methods: Young adults with neurological disease, spasticity and increased risk of skin breakdown (due to pressure, friction or shear) from inadequate bed/wheelchair positioning were treated. An interdisciplinary team including the resident, a SWAT (skin and wound assessment and treatment) physiotherapist, and physiatrist assessed for appropriateness of BTX-A* therapy. A product specialist was available for consult. Recommendations1 assisted the team at initial assessment in determining goals, and injection sites. Follow up occurred 6 weeks post injection and as required. Evaluation tools included tone and passive range of motion assessment; photographs; video; and resident/staff feedback.
Results: BTX-A* injections into targeted muscles occurred a minimum of 3 months apart. Reduction of tone resulted in improvements in sitting posture, sitting tolerance, positioning device(s) use, and the elimination of friction as a risk to skin breakdown. Resident satisfaction was high as function improved without the same potential systemic side effects as anti-spasticity medications.
Conclusion: BTX-A*, which decreases tone by blocking the release of acetylcholine at the neuromuscular junction,2 has demonstrated positive results in positioning and use of interventions to prevent or treat skin breakdown. The product works locally and has a relatively benign side effect profile in this application.3
*Botox (Allergan, Inc., Irvine, Calif.)
References
1. The WE MOVE Spasticity Group. Dosing, administration, and a treatment algorithm for use of botulinum toxin type a for adult-onset muscle overactivity in patients with an upper motoneuron lesion. In; Mayer NH, Simpson DH, eds. Spasticity: Etiology, Evaluation, Management and the Role of Botulinum Toxin. We Move Worldwide Education and Awareness for Movement Disorders. 2002;154-165.
2. Brin M, Aoki KR. Botulinum toxin type a: pharmacology. In; Mayer NH, Simpson, DH eds. Spasticity: Etiology, Evaluation, Management and the Role of Botulinum Toxin. We Move Worldwide Education and Awareness for Movement Disorders. 2002;110-121.
3. Aoki, KR, Childers MK. Pharmacology in pain relief. In; Childers MK, ed. The Use of Botulinum Toxin Type A in Pain Management.
Evaluation of a porcine substrate in the wound healing of significant compromised wounds
Nikolis A, Harris PG, Cordoba C, Ciaburro H, Brutus JP, Saint-Cyr M, Sampalis JS
Wound healing is a complex sequence of events. Failure of the healing process results in chronic wounds impacting on the patient directly through progression to systemic sequelae, diminished quality of life, and impaired return to activities of daily living. These failures are also associated with increased health care utilization and costs.
The purpose of the current study was to evaluate the efficacy of OASIS®, a biologically derived, extra-cellular collagen based porcine small-intestine sub-mucosal matrix, in accelerating the healing of chronic wounds in compromised patients.
This was a prospective single cohort study of patients with refractory chronic wounds with i) prior failure with two or more established treatment regimens, ii) presence of two or more systemic risk factors and iii) a non-healing wound for a minimum of 60 days. All patients were treated with OASIS®.
Twenty five patients with a mean (SD) age of 54.8 (16.1) years evaluated. The mean (SD) duration of treatment in the healed patients was 54 (18.1) days with a range of 30 - 205 days. Wounds were present for 195.7 (299.60) days (range of 60 - 1,200). Following completion of the OASIS protocol, 52% of the previously unresponsive wounds went on to complete wound healing. Outcomes following matrix use with specific emphasis on adverse events, and new protocols for its use will be presented.
These results show that OASIS® is safe, effective, and provides a promising alternative in the management of refractory wounds. Further studies based on better-defined patient populations will be required to better evaluate this intervention.
References
RGD Study Group. Steed DL; Ricotta JJ; Prendergast JJ; Kaplan RJ; Webster MW; McGill JB; Schwartz SL. Promotion and acceleration of diabetic ulcer healing by arginine-glycine-aspartic acid (RGD) peptide matrix. Diabetes Care. 1995;18(1):39-4.
Day MR, Fish SE, Day RD. The use and abuse of wound care materials in the treatment of diabetic ulcerations. Clin Podiatr Med Surg. 1998;15(1):139-150.
Measurement methods of ulcers
Chikako K. Poffenberger; Frank Ronald Fisher; Vancouver Island Health Authority, Queen Alexandra Centre
An important aspect of the diabetic ulcer treatment is the assessment of and monitoring the size of ulcers. The ulcers are often irregular in shape and irregular in depth; therefore, it is not easy to measure ulcers. There are many reports on measuring the two-dimensional size. The computerized measurements are reported to be more accurate. However, some of the methods are time consuming and expensive to use in the clinical setting. “Scion image” provides free software available on the web. This method requires only a digital camera and a computer. The usage and the method of this software are explained in this presentation.
There have been few reports made on the volume measurements of ulcers. One attempt was using saline solution. It is useful when the ulcer surface is in a horizontal plane to keep the saline in. Another method was using dental impression. However, this method was found to be time consuming and difficult to apply. The standard deviation of this method was 5% to 16%. The computer method for volume measurement is expensive, and its accuracy measuring deep or undermined ulcers was questionable. The method introduced in this study is using seaweed agar. Its accuracy was tested by nine clinicians measuring two wound cavities on a plaster model. Results showed standard deviations 4.9% and 8.9% for inter-tester reliablility, and 4.2% and 4.8% for intra-tester reliability. This appears to be an easy, inexpensive, and reliable method to apply in both a clinical or research setting.
References
Berg W, Traneroth C, Gunnarsson A, Lossing C. A method for measuring pressure sores. Lancet. 1990;16;335(8703):1445-1446.
Covington JS, Griffin JW, Mendius RK, Tooms RE, Clifft JK. Measurement of pressure ulcer volume using dental impression materials: suggestion from the field. Phys Ther. 1989;69(8):690-694.
Kubanek J, Jensen PR, Keifer PA, Sullards MC, Collins DO, Fenical W. Seaweed resistance to microbial attack: a targeted chemical defense against marine fungi. Proc Natl Acad Sci. 2003;100(12):6916-6921.
Langemo DK, Melland H, Hanson D, Olson B, Hunter S, Henly SJ. Two-dimensional wound measurement: comparison of 4 techniques. J Wound Care. 1997;6(3):123-126; Adv Wound Care. 1998;11(7):337-343.
Mayrovitz HN, Smith J, Ingram C. Comparison of venous and diabetic plantar ulcer shape and area. Adv Wound Care. 1998;11(4):176-183.
Oien RF, Hakansson A, Hansen BU, Bjellerup M. Measuring the size of ulcers by planimetry: a useful method in the clinical setting. J Wound Care. 2002;11(5):165-168.
Plassmann P, Melhuish JM, Harding KG. Methods of measuring wound size: a comparative study. Ostomy Wound Manage. 1994;40(7):50-2, 54,56-60.
Taylor RJ. Mouseyes: An Aid to wound measurement using a computer. J Wound Care. 1997;6(3):123-126.
Thawer HA, Houghton PE, Woodbury MG, Keast D, Campbell K. A comparison of computer-assisted and manual wound size measurement. Ostomy Wound Manage. 2002; 48(10):46-53.
Vlachos V, Critchley AT, von Holy A; Establishment of a protocol for testing antimicrobial activity in southern African macroalgae. Microbios. 1996;88(355):115-123.
The importance of avoiding contact allergens in persons with leg ulcers
V. Smart, BscH; P. Noseworthy, MD; L. Holness, MD; P. Coutts, RN; M Fierheller, RN, BScN; R. G. Sibbald, MD; Toronto Wound Healing Centres, Mississauga, Ontario, Canada
Individuals with chronic leg ulcers often develop reactions to topical preparations used on their wounds and the surrounding skin. Unfortunately Cameron has reported that topical applications sensitize 51% to 78% of leg ulcer patients and many other individuals with chronic wounds. Because of this information and need to validate similar occurrences in the Canadian population, we enrolled 68 consecutive individuals with chronic leg ulcers who were available for patch testing into a case series. Ethics approval was obtained and patch test kits for 39 common allergens were assembled for our two clinical sites.
The most common allergens identified from patch testing include:
1. Wood tar mix 9.9% (Perfume group)
2. Bacitracin 6.3% (Antibacterial)
2. Wood alcohols 6.3% (Lanolin group)
4. Cetyl stearyl alcohol 5.4% (Lanolin group)
4. Benzoyl peroxide 5.4% (Acne/Ulcer medications)
4. Balsam of Peru 5.4% (Perfume group)
4. Polymyxin B 5.4% (Antibacterial)
8. Amerchol 4.5% (Lanolin group)
8. Fusidic acid 4.5% (Antibacterial)
8. Carba mix 4.5% (Rubber products)
8. Benzylalkonium chloride 4.5% (Antiseptic)
Most of the common allergens are from the Perfume group, Antibacterials, or related to Lanolin (eight out of 11). Several allergens were more likely to be found in combination. These results should lead us to be more discerning about the topical agents ordered for persons with leg ulcers and other chronic wounds. A list of common sources of these allergens will be presented and this data could serve as a basis for future wound care education and products.
References
Cameron J. The importance of contact dermatitis in the management of leg ulcers. In: Moffat C, Harper P, Access to Clinical Education: Leg Ulcers. New York, NY: Churchill Livingstone Inc.;1997:182-185.
Fisher A. The role of patch testing. In: Fisher A, ed. Contact Dermatitis, Third Edition. Philadelphia, Pa.: Lea And Febiger;1986:9-29.
Educational Abstracts
High-risk foot care protocol for occupational therapists — Calgary Home Care, Skin, and Wound Assessment and Treatment (SWAT) team
Gillian Bagg, BScOT; and Shannon McGrath, BScOT
The need for assessment and treatment of high-risk feet became a focus for two occupational therapists of the Calgary Home Care Skin and Wound Assessment and Treatment (SWAT). Team as part of an interdisciplinary approach to wound care for clients who had poor community follow up for existing foot health problems. Preliminary research was completed to determine occupational therapy scope of practice and resources available in the community. The High-Risk Foot Care Protocol for Occupational Therapists was developed based on best current evidence and best practice guidelines related to the high risk foot.
The protocol is intended to assist skin and wound professionals to identify high risk feet and to facilitate appropriate and timely interventions as a means of prevention. The protocol addresses assessment of risk, (neuropathy, deformity, joint mobility, circulation, history of ulcers) and interventions including pressure offloading/downloading, edema control, and patient education. A quick reference guide was developed from the protocol for use during consultation. Resources are provided including referral locations for complete assessment and fabrication of therapeutic devices.
In addition, the protocol was presented at a regional education day to skin and wound professionals to increase awareness of the need for this vital interdisciplinary consultation. To support the continued implementation of this protocol, resource binders have been compiled and are available at all Calgary Home Care sites and clinics. The effectiveness of the protocol in the management of the high risk foot will be reviewed by the SWAT team Occupational Therapist in 2005.
References
Inlow S, Orsted H, Sibbald G. Best practices for the prevention, diagnosis and treatment of diabetic foot ulcers. Ostomy Wound Manage. 2000;46(11):55-68.
Stacpoole-Shea S, et al. An examination of plantar pressure measurements to identify location of diabetic forefoot ulceration. J Foot Ankle Surg. 1999;38(2):109-115.
Goldsmith JR, et al. The effects of range-of-motion therapy on the plantar pressures of patients with diabetes mellitus. J Am Podiatr Med Assoc. 2002;92(9)483-490.
Pressure ulcers prevention and treatment
Gail Thompson RN, BN, ET, Chinook Health Region, Ostomy and Wound Clinic, Lethbridge, Alberta
Purpose: The goal of this project was to create a evidence-based educational tool for pressure ulcers and to develop a strategy for increasing staffs knowledge on prevention and treatment.
Objectives: The poster is an educational tool depicting the key elements in early detection and treatment of pressure ulcers. The following key factors will be identified: pressure ulcer identification, development of a plan of care, nutritional assessment and support, management of tissue loads, regular review and assessment of the principles of wound management. An evidence-based algorithim on moist wound healing will assist the healthcare professional in selecting a appropriate dressing to achieve the goals of hydration, reduced bioburden, exudate balance, pain management, prevention of maceration, and to protect the wound from further injury.
Outcome: The poster identifies the six risk areas for developing pressure ulcers: sensory perception, skin moisture, activity, mobility, nutrition and friction/shear. The strategic plan is to increase staff’s knowledge on prevention and management of pressure ulcers. The instrument is evidence-based and promotes the standard principles of wound management. Selection of appropriate dressings to achieve moisture balance will improve patient outcomes and demonstrate to be cost-effective.
Conclusion: Healthcare professionals and institutions must acknowledge pressure ulcers are serious and must not be ignored. A team approach to pressure ulcer management and a commitment to prevention, risk assessment and early intervention are needed from healthcare professionals. To increase staff awareness of pressure ulcers and to assist staff in the decision making process in the treatment of Stage I, Stage II, Stage III, and Stage IV, an educational tool can be proven to be effective with positive patient outcomes.
References
1. Bryant RA. Acute and Chronic Wounds. St. Louis, Mo.: Nursing Management Mosby Year Book;2000.
2. Krasner D, Rodeheaver G, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, Pa.: HMP Communications;2001.
3. McIssac C. Department of Health. Evidence Based Wound Management Protocol Community Care Government of Nova Scotia; 2000.
4. Rodeheaver, GT. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Kane, D. Chronic Wound Care, Second Edition. Wayne, Pa.: Health Management Publications Inc.;1997.
Therapeutic surfaces — a strategic approach to decision making
Deborah Mings, RN, MHSc, ACNP, Clinical Nurse Specialist; Diane Tait, OT Reg (Ont); Susan Rivers, RN, MscT; St. Peter’s Hospital, Hamilton, Ontario
Choosing the best preventative and therapeutic surface for a specific patient population can be a clinical conundrum. Limited resources, prioritizing clinical allocation, costs and issues associated with renting versus owning surfaces, and choosing from the burgeoning choices and vendors can make this a daunting issue to address.
In our chronic care setting, patients have significant and ongoing risk factors that make them vulnerable to the development of skin breakdown. Therapeutic and preventative surfaces are an integral component of patient care and a part of the comprehensive approach to prevention and wound management. The questions we addressed: “How do you know which surface is the best? Under what circumstance do you chose one surface over another?”
Our hospital undertook an interdisciplinary, multifaceted approach to choosing preventative and therapeutic surfaces. We reviewed literature for best practices. We trialed products and obtained feedback from staff and patients. We pressure-mapped a variety of pressure-relieving and pressure-reducing surfaces. We ultimately decided to buy the majority of our surfaces but included the option to rent based upon specific criteria. Occupational Therapy and Nursing have developed an algorithm that is used to determine surface selection based on patient characteristics, need and available resources.
This presentation will outline the role of pressure mapping, the criteria for purchase of surfaces, and the development of an algorithm to guide practice. We will discuss our hospital experience with choosing therapeutic and preventative surfaces for our geriatric population of patients.
A pocket guide for wound care for use in long-term care
Dawn Christensen, BScN, RN, ET, MHScN; Kimberly LeBlanc, BScN, RN, ET, MN(c); Consultants, Clinicians, and Educators with KDS Professional Consulting, Ottawa, Ontario
Providing education to the front line workers who are involved in the day-to-day care of the patient with wounds is an important responsibility of any wound care professional. Education can take many forms. Lecture format is often an effective way to provide adults with new material, but according to Sibbald et al (2001) it does not significantly change their behaviour unless there is a follow-up secondary education strategy. Examples of secondary education strategy are a chart remainder or a simplified memory reminder.
As wound care educators, we at KDS Professional Consulting like to provide an easy reference guide to attendees of our wound care sessions to reinforce the learning that has occurred during the session. There are many guides available, produced by industry, but we wanted to create our own that would reinforce our education sessions.
This poster presentation is a demonstration of our pocket guide. The guide is small enough to fit into a pocket, or hang on a “med cart” in a long-term care facility. It is a multi page reference that is user friendly. Within the pages are the answers to many of the questions that a nurse working in long-term care will have about wound care. During the conference we welcome feedback from the attendees regarding any suggested changes or improvements.
References
Bergstrom N, Allman RM, Carlson CE, et al. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. Rockville, Md.: US Department of Health and Human Service. Agency for Health Care Policy and Research; 1994. ACHPR Publication No 95-0652
Sibbald RG, Davis D, Rath D. Effective adult education principles to improve outcomes in patients with chronic wounds. In: Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition 2001. Wayne, Pa.: Health Management Publications, Inc.:25-34.
Sibbald RG. Topical antimicrobials. Ostomy Wound Manage. 2003;49(5suppl):14S-18S.
Burrell RE. A scientific perspective on the use of topical silver preparations. Ostomy Wound Manage. 2003;49(5):19-24.
Public Policy Abstracts
Implementation of a regional wound assessment and treatment record for continuing care
Carol Anderson, RN, BscN; Capital Health - Community Care Services
Issue: Capital Health provides continuing care services to 4,478 residents at 32 continuing care centres. Each continuing care organization had developed different methods for documenting the assessment and treatment of wounds. The lack of a consistent documentation process for wound care resulted in confusion when residents were referred to wound clinics or transferred to acute care or another continuing care centre.
Project: The Capital Health Continuing Care Regional Wound Care Committee formed a working group with representation from public, private, and voluntary continuing care organizations to address this issue. The working group was charged with the task of developing a wound assessment and treatment record for use in all Capital Health continuing care centres.
Results: Utilizing a collaborative approach, facilitated by the Continuing Care Practice Leader (a regional position), a wound assessment and treatment record was created. The form records pertinent assessment data, information about the clinical status of the wound, the treatment protocol, dressing change documentation, and anecdotal notes. The form also was designed to support the continuing care centres in the regional reporting process of quality indicator data on chronic wounds.
The form was pilot tested for 2 months and feedback from the continuing care centres was incorporated into the final document. The Continuing Care Wound Assessment and Treatment Record was implemented regionally in September 2004. The form has been positively received by both the continuing care centres and the acute care hospitals. The form has facilitated consistent documentation of wound care information and thereby enhanced resident care. It is possible to develop and implement regional initiatives when a collaborative process is utilized.
Prevalence of the need for compression therapy in a complex care facility
Jim Oldnall, RN, GNC(C), Victoria; Sandy Daughen, BHSc(OT), OT, Victoria; Annette Elieff, BSc(OT), OT, Victoria
After attending the 2002 CAWC Annual Conference, the authors identified the need to implement best practice guidelines in the area of compression therapy at The Lodge at Broadmead, a 225-bed complex care facility in Victoria, BC. The authors believed that current methods for screening residents for compression therapy were not identifying all residents who could benefit from the use of compression. In order to determine the prevalence of residents who could use compression, the authors completed a chart review of all 225 residents residing in the facility over a 3-month period. The chart review identified all residents with medical diagnoses, conditions, or other relevant indicators who might benefit from the use of compression therapy. The authors determined the categories based on a literature review of best practices in the area of compression therapy. The categories included: history of a venous leg ulcer, history of cerebrovascular accident or transient ischemic attack, congestive heart failure, peripheral vascular disease, smoking, diabetes, edema, current use of compression therapy, immobility, and varicose veins/varicosities. The poster will discuss the results of the audit, which indicated that approximately 40% of the residents had at least three risk factors that would indicate the need for evaluation for compression therapy. Less than half of these residents are currently using compression therapy, indicating that current screening methods are not identifying all residents who could benefit from compression therapy. This poster also will outline proposed changes to screening and assessment to incorporate an enhanced approach to compression therapy.
References
Kunimoto B, Cooling M, Gulliver W, Houghton P., Orsted H, Sibbald RG. Best practices for the prevention and treatment of venous leg ulcers. Ostomy Wound Manage. 2001;47(2):34-50.
Orsted H, Radke L, Gorst R. The impact of musculoskeletal changes on the dynamics of the calf muscle pump. Ostomy Wound Manage. 2001.
Taking the pressure off: using a program planning approach to change practice in an intensive care unit
D. Faye Kendel, RN, CNCC (C); Tessa Diston, RN, BScN CNCC (C); Nancy White, RN, BA, CNCC; Laura Teague, RN, MN, ACNP; Allison Rankine, RN, ET; St. Michael’s Hospital
The onset of critical illness exposes patients to intrinsic and extrinsic risks associated with pressure ulcers. Over the past 6 years, our tertiary care medical-surgical intensive care unit has demonstrated these risks annually, through both high point-prevalence and incidence surveys. Development of a corporate wound care team, adoption of a risk assessment tool, and education sessions were implemented to address the clinical and quality outcomes related to pressure ulcers. While the impact of this approach has resulted in hospital wide reduction of prevalence, our medical-surgical intensive care patients continued to develop pressure ulcers.
Through a program planning approach, a group of professional registered nurses within our medical-surgical intensive care unit have developed a strategy to identify gaps in structure of assessment and a proactive process for interventions aimed at prevention versus treatment. The new-unit based wound care team has planned and implemented a skin integrity program that includes: daily risk assessment, education sessions specific to the intensive care population, and unannounced quarterly audits which include prevalence, staging of ulcers, interventions in situ, and use of therapeutic surfaces.
This presentation will highlight the program planning process which has resulted in a shift from treatment to prevention.
References
1. Aucoin JL. Program planning: Solving the problem. In: Kelly-Thomas K. Clinical and Nursing Staff Development; Current Competence, Future Focus. Philadelphia, Pa.: Raven Publishers;1998:213-239.
2. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk. A multisite study of the predictive validity of the Braden scale. Nursing Research. 1998;47(5):261-269.
3. Dolynchuk K, Keast D, Campbell K, Houghton P, Orsted H, Sibbald G, Atkinson A. Best practices for the prevention and treatment of pressure ulcers. Ostomy Wound Manage. 2000;46(11):38-52.
4. Pollack CD. Planning for success: the first steps in new program development. Journal of School Nursing. 1994;10(3):11-15.
5. Sibbald R, Williamson D, Orsted H, Campbell K, Keast D, Krasner D, Sibbald, D. Preparing the wound bed - debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46(11):14-35.
Adoption of a tool to document wound care assessment, interventions, and outcomes in wound care centres
Willey C, RN, BN; Juchymenko J, OT; Carewest, Care Centre SWAT Team - Calgary, Alberta
Treating wounds is very costly for care centres. Residents with wounds are complex and challenging for health care professionals.1 Experts agree that wound care requires a holistic, interdisciplinary approach, thorough assessment and evaluation for optimal resolution.2 Collectively, Calgary Health Region (CHR) care centres had no formal standard practice to monitor wound progress and outcomes. The 29 centres required a template for consistent documentation with clear resident-centered goals to ensure continuity of care.
The Care Centre Skin and Wound Assessment & Treatment (CCSWAT) Team recognized the need to adopt a protocol reflecting best practice guidelines for monitoring wounds and provide a comprehensive structured approach to document wound assessment, treatment, and outcomes.
The Clinical Specialist, Skin and Wound Management, for Calgary Home Care and CCSWAT developed and successfully implemented a Clinical Wound Pathway for home care.3 Over several months, this tool was modified to suit care centre needs and piloted. Feedback throughout this process indicated that successful implementation required this tool to be time efficient, user-friendly, minimize documentation, and show improvements over current practices to both management and front-line users. Once objectives were met the tool was accepted and renamed. A recommendation was made to the CHR Quality Service Committee (QSC) that each facility adopts this protocol into practice.
CCSWAT is dedicated to supporting the delivery of evidence-based interdisciplinary, individualized, cost effective skin and wound care and recommends process enhancement initiatives to the CHR QSC. The adoption of the Wound Care Flow Sheet is one example of a successful initiative.
References
1. Dolynchuk K., Keast D, Campbell K, Houghton P, Orsted H, Sibbald G. Atkinson A. Best practices for the prevention and treatment of pressure ulcers. Ostomy Wound Manage. 2000:46(11):39-52.
2. Sibbald G, Williamson D, Orsted H, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed - debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000:46(11):17-35.
3. Orsted, H. Clinical wound pathway. Calgary Home Care. 2001.
Research Abstracts
Leg ulcer measurement tool (LUMT): more about its ability to detect change
M. Gail Woodbury, BScPT, MSc, PhD, Lawson Health Research Institute; Epidemiology & Biostatistics, University of Western Ontario, London, Ontario; Pamela E. Houghton, BScPT, PhD, School of Physical Therapy, University of Western Ontario; Lawson Health Research Institute; Karen E. Campbell, RN, MScN, PhD candidate, Specialized Geriatric Program, St. Joseph’s Health Care London; Lawson Health Research Institute; School of Nursing, and Rehabilitation Science, University of Western Ontario, London, Ontario; David H. Keast, BSc, MD, CCFP, Parkwood Hospital, St. Joseph’s Health Care London; Lawson Health Research Institute; Department of Family Medicine, University of Western Ontario, London, Ontario
The recently developed and validated LUMT consists of 14 clinician-rated domains. The total LUMT score ranges from zero, a healed ulcer, to 56. For the LUMT to be useful to detect changes in wound status, its sensitivity to change must be demonstrated. This property was tested during the initial validation study with a small number of subjects (n = 19). The purpose of this project was to use a larger sample to confirm the ability of the LUMT to detect wound improvement or deterioration in chronic venous ulcers following implementation of a standardized wound care protocol. We received a data set in which LUMT was included as one of the outcome measures for a large multicentre study (Principal Investigator M. Harrison) examining the effectiveness of implementing evidence-based clinical practice guidelines in the community. Chronic leg ulcers were assessed on two occasions using the LUMT (n = 96). Effect size, defined as mean change in LUMT score divided by the standard deviation (SD) of the initial score, describes sensitivity to change. Effect sizes larger than one indicate change that is greater than one SD. The effect size for the total LUMT score was 2.23, which would be considered large by Cohen. For the individual domains the effect sizes ranged from 0.22 to 1.76. Analysis of this larger sample of home care patients indicates more definitively that the total LUMT is sensitive to change and thus could be a useful both clinically and to demonstrate the effectiveness of wound care programs.
References
Woodbury MG, Houghton PE, Campbell KE, Keast DH. Development, validity, reliability and responsiveness of a new leg ulcer measurement tool (LUMT). Adv Skin Wound Care. 2004;17:187-196.
Woodbury MG, Houghton PE, Campbell KE, Keast DH. The leg ulcer measurement tool (LUMT) detects change in wound appearance. Ostomy Wound Manage. 2002;48(4):80.
Kazis LE, Andersen JJ, Meenan RF. Effect size for interpreting changes in health status. Med Care. 1989;27(3,suppl):S178-S189.
Cohen J. Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum;1988.
The effectiveness of electrical stimulate to promote wound closure: a systematic review
Pamela E. Houghton, Aaron S. Foster, Wendi C. Smith, E. Todd Taylor, Lisa M. Zinkie; School of Physical Therapy, University of Western Ontario
Objectives: (1) To determine the effectiveness of electrical stimulation (ES) to promote the closure of ulcers. (2) To establish inter-rater reliability of PEDro and Jadad methodological evaluation scales.
Data sources: Electronic database and bibliography searches were used to find related clinical trials. The list of search terms focused on: wound, ES and healing. Searches were limited to human, adult clinical trials.
Study selection: Consensus between reviewers was required to accept articles at each phase. Inclusion criteria: individuals with skin ulcer(s), ES treatment, wound healing, independent control group and between-group statistical comparisons.
Data extraction: Trends were identified through group analysis following independent data extractions. Methodological rigor was examined using Jadad and PEDro, and inter-rater reliability I.C.C. (2,1) values were obtained.
Data synthesis: Of the 2,265 articles identified, 17 studies were accepted. Eleven reported improved wound closure, six showed no difference. The total number of subjects in the ES group was 483 and 334 in the control group. Studies reporting accelerated wound closure used design characteristics or treatment parameters such as randomization, large sample sizes (n e 25), similar baseline characteristics, negative or alternating polarity, frequencies e 64 Hz, monophasic pulsed current or treatment of pressure ulcers. Jadad and PEDro achieved inter-rater reliability of 0.74 (0.56-0.86) and 0.64 (0.44-0.80), respectively.
Conclusions: The majority of articles accepted supported the use of ES as an effective adjunctive therapy for wound closure. Inter-rater reliability values for PEDro and Jadad indicated novice clinicians could achieve moderate reliability.
References
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds JM, Gavaghan et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Controlled Clin Trials. 1996;17:1-12.
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721.
Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86(2):410-428.
The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a systematic review
G Nicosia, RS Cavanagh, AE Gliatta, RS Schecter, JL Tiffney, School of Physical Therapy, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada; C Anderson, London Health Sciences Center; MG Woodbury, Lawson Health Research Institute; Epidemiology & Biostatistics, The University of Western Ontario; PE Houghton, Lawson Health Research Institute
This systematic review searched and evaluated randomized controlled trials (RCTs) that examined the ability of mattresses, overlays and devices to prevent the occurrence of heel ulcers in a variety of settings. Literature searches of CINAHL, MEDLINE, PubMed, EMBASE, and Cochrane databases were conducted using the following inclusion criteria: English language, human subjects (>18 years), measured incidence or number of heel ulcers, RCT design and studies that investigated pressure relief interventions with or without concurrent prevention programs. Abstracts were reviewed and copies of full articles were selected and read independently by a minimum of two researchers. Study inclusion was decided based upon consensus by a group of five researchers. Group consensus was reached for scores of two established scales (PEDro and Jadad) that assessed methodological quality of RCTs. A quantitative analysis was performed to determine and compare relative risk (RR) and relative risk reduction (RRR) between pressure relief programs/devices that were classified according to similarity of interventions. The RR and RRR with 95% confidence intervals (95% CI) were calculated using pooled data and depicted in forest plots. Literature search revealed 812 abstracts from which 96 relevant articles were retrieved and reviewed. Thirteen published articles that surveyed a total of 1,217 subjects were included in the final analysis. When compared to a standard hospital mattress, air or foam overlays significantly reduced the risk of developing heel pressure ulcers (RR=0.50, 95% CI 0.26-0.93, P = 0.03).
References
Aronovitch SA, Wilber M, Slezak S, Martin T, Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy Wound Manage. 1999;45:34-44.
Takala J, Varmavuo S, Soppi E. Prevention of pressure sores in acute respiratory failure: a randomized controlled trial. Clin Intensive Care. 1996;7:228-235.
Vyhlidal SK, Moxness D, Bosak KS, Van Meter FG, Bergstrom N. Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers. Appl Nurs Res. 1997;10:111-120.
Braden scale: is it easy to use?
Kevin Woo, BSc, MSc, ACNP; North York General Hospital, Toronto, Ontario; Sandra Tully, BSc, MN, ACNP, University Health Network, Toronto; Pam Savage, BSc, MN, University Health Network Toronto
The Braden scale is one of the most intensively studied risk assessment scales used in identifying patients who are at risk of developing pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. Reviewing the findings in three studies, Braden and her colleagues (1987) reported that reliability for the Braden Scale could range from r = .83 to r = .94 for nurses’ aides and licensed practical nurses. When used by registered nurses, the reliability of the Braden scale increased to r = .99. Little is known the amount of education that is required to achieve sufficient inter-rater reliability. The purpose of the study is to determine if nursing staff can learn to use the Braden scale without extensive training in an unstructured and informal format. Forty-two nurse mentors from four teaching hospitals were asked to educate two staff nurses in the use of Braden Scale. The mentors and the staff nurses were asked to select a patient and independently assess the risk of pressure sore using Braden Scale. Interrater reliability was calculated. Results indicated that the reliability ranged from r = 0.76 to r = 0.99. Nutrition, moisture, and sensory/perception were the categories where disagreement between raters were commonly observed. This finding suggested that nurses can learn how to use the Braden scale with mentorship without extensive training.
