SAWC Fall 2018 Poster Abstracts

Case Series/Study

Rosemary Hill, BSN, CWOCN, WOCC (C); and Joshua Douglas, MD, FRCPC, ABIM

Introduction: Wound cleansing is the most ubiquitous method to maintain optimal wound hygiene. The periwound is often a neglected area but serves as a source for microbial recontamination if not adequately cleansed. Fluorescence imaging has been used to visualize red-fluorescing, pathogenic bacteria in the wound bed and periwound area at the bedside using a noncontact, handheld device. The visualization of bacterial load can be incorporated to optimize wound hygiene by guiding targeted cleansing and debridement.

Objective: Recently available, improved skin and wound cleansing agents with lower concentrations of sodium hypochlorite, which are purported to disrupt biofilm and kill planktonic bacteria while still safe for the wound bed, may optimize wound hygiene. The effectiveness of such cleansers compared with standard practice is reported here.

Method: In this series of 10 patients, bioburden reduction was assessed by fluorescence imaging and visualization of bacterial load. The wound bed and periwound area were cleansed using saline or 0.057% sodium hypochlorite.

Results: Of the 10 patients, 9 had bacterial load present outside of the wound bed, and periwound/wound cleansing with traditional saline was not sufficient to remove bacterial load from 9 patients. In 6 of 9 patients, the 0.057% sodium hypochlorite was effective at eradiating bioburden; however, 3 of 9 required debridement to fully eliminate the bioburden.

Conclusions: Timely management of wound bioburden is imperative to support overall healing. Wound hygiene can only be possible if the location of bioburden is identified in the wound/periwound area and removed with effective cleansing agents.

Recipient of 1^st Place Award in Case Series/Study Category

Clinical Research

William Tettelbach, MD; Shawn Cazzell, DPM; Felix Sigal, DPM; Joseph M. Caporusso, DPM; Patrick Agnew, DPM; Jason Hanft, DPM; and Cyaandi Dove, DPM

Objective: This study seeks to determine the safety and effectiveness of a dehydrated human umbilical cord allograft for the treatment of chronic, nonhealing diabetic foot ulcers (DFUs).

Materials and Methods: An institutional review board-approved, multicenter, randomized, controlled trial was conducted at 11 centers in the US. Individuals with diabetes and a DFU measuring 1 cm² to 15 cm² below the ankle for at least 30 days were eligible for the 14-day run-in phase with weekly debridement, moist wound therapy, and offloading. Those with > 30% wound area reduction post-debridement were randomized in a 2:1 ratio to receive a weekly application of the allograft (n=101) or standardized therapy with alginate wound dressing, nonadherent silicone dressing, absorbent nonadhesive hydropolymer secondary dressing, and gauze (n=54). All DFUs were appropriately offloaded. Study visits with debridement, wound photography, measurement, and treatment-group specific dressings were conducted for 12 weeks. Primary outcome was the percent of DFUs with complete closure within 12 weeks. Data were evaluated using an intent-to-treat (ITT) analysis (n=155). Additional analysis was conducted on patients completing the study per protocol (PP) (n=134: allograft, n=86; alginate, n=48), and for those receiving adequate debridement (allograft, n=67; alginate, n=40).

Results: The ITT analysis showed DFUs treated with the allograft had higher healing rates within 12 weeks compared with those receiving alginate dressings, 71 of 101 (70%) versus 26 of 54 (48%) for allograft and alginate dressings, respectively (P=.0089). The PP healing rates at 12 weeks were 70 of 86 (81%) for allograft-treated and 26 of 48 (54%) for alginate-treated DFUs (P=.0013). For those DFUs with adequate debridement (n=107, ITT population), 64 of 67 (96%) of the allograft-treated ulcers healed completely within 12 weeks, compared with 26 of 40 (65%) of alginate-treated ulcers (P<.001). One-hundred and sixty adverse events were reported from 75 patients. None were related to either allograft or alginate dressings.

Conclusions: These results demonstrate the importance of adequate wound debridement and the safety and efficacy of dehydrated human umbilical cord allograft as a treatment for nonhealing DFUs.

Recipient of 1^st Place in Clinical Research Category

Information/Educational Report

Sonya Dick, PT, DPT, CWS, FACCWS; and Ana-Clara Tolentino, RN, MSN, MBA, WOCN, PhD

Introduction: Incontinence-associated dermatitis (IAD) is a major concern with hospitalized patients and puts them at higher risk for skin breakdown and ulceration. Zinc oxide has been proven to prevent and treat IAD.

Objective: Proposed utilization of a touch-free zinc oxide system (TFZO) to treat IAD in acute care patient population will demonstrate responsible use of resources, preservation of patient/caregiver dignity, and reduction of cross-contamination.

Methods: A literature search was conducted to gather data for prevalence of IAD, average length of stay (LOS), and time to heal (TTH). Prevalence of IAD was 20% and 27%, respectively, in 2 acute care studies. Average LOS for IAD patients was found to be 5.5 to 7 days and TTH was 7 to 9 days. Average unit costs per product were included in the analysis and calculated for sample Hospital XYZ, a 250-bed acute care facility.

Results: Using a computational model based on the literature review and data for prevalence, LOS and TTH costs were calculated, comparing application of TFZO treatment versus direct gloved application of zinc oxide ointment per group of patients (62.5) treated at an averaged prevalence rate of 25%. There was a range of realized cost reduction of $181.88 to $730.63 per week or $9457.50 to $37 992.50 over a 12-month period for Hospital XYZ.

Conclusions: The TFZO application system is a unique example of how product presentation can be innovative in reducing health care costs. Accomplishment of cost savings, preserving patient dignity, reducing cross contamination risks, and reducing product waste should be encouraged when hospitals are seeking to provide quality care along with patient/caregiver satisfaction.

Recipient of 1^st Place in Information/Educational Report Category

Laboratory Research

Stephen Davis; Jie Li, MD, PhD; Joel Gil; Jose Valdes; Michael Solis; and Alexander Higa

Introduction: Topical antimicrobials are widely used to control wound bioburden and facilitate wound healing; however, the fine balance between antimicrobial efficacy and nontoxicity must be achieved.

Objective: This study evaluated the effect of an advanced antimicrobial dressing on the healing of deep partial-thickness wounds.

Materials and Methods: In an in vivo porcine wound model using 2 pigs, 48 deep partial-thickness wounds (12 mm x 12 mm x 0.5 mm) were created on each animal for a total of 96 wounds. Wounds were randomly assigned to 1 of 3 treatment groups: advanced antimicrobial dressing (AAA), silver hydrofiber dressing (SHD), or polyurethane film dressing (PU). Wounds were treated for 8 days and wound biopsies (n=4) were taken from each treatment group, per animal, on days 2, 4, 6, and 8 after wounding and evaluated using light microscopy.

Results: No statistically significant differences were observed in the rate of reepithelialization, white blood cell infiltration, angiogenesis, or granulation tissue formation following treatment of wounds with the AAA dressing versus the SHD and PU dressings. Overall, epithelial thickness was similar between groups. Some differences in infiltration of specific cell-types were observed between treatment groups. Overall, there were no signs of tissue necrosis, fibrosis, or fatty infiltration in any treatment group.

Conclusions: In vitro and in vivo effectiveness of the AAA dressing has previously been reported; this study has demonstrated that the dressing does not impair tissue repair, which is equally important in delivering optimal wound care.

Recipient of 1^st Place in Laboratory Research Category

Case Series

April Lumpkins, RN; and Tamara Stanton, RN

Introduction: Patient nonadherence to wound care protocols may impact the efficacy of modalities, such as negative pressure wound therapy (NPWT). Recently, a remote therapy monitoring (RTM) system has been devised for use with NPWT for patients receiving homecare in order to improve patient adherence to NPWT.

Objective: In this series, the authors present 3 cases that examine the relationship between patients using the aforementioned RTM system as well as virtual therapy specialists (VTS).

Case 1: A 78-year-old woman was discharged home with a RTM-equipped NPWT unit to manage a sacral pressure injury after an acute inpatient stay. In the first week, the VTS discovered the patient was legally blind and lived alone with cats that would sit in her lap and inadvertently turn off the unit, causing frequent nonadherence. The VTS alerted the patient’s clinician and coordinated a resolution to the issues, allowing her to remain adherent to therapy (10 nonadherent vs. 39 adherent days).

Case 2: A 57-year-old woman, who developed a surgical site infection after a ventral hernia repair, was discharged home with a RTM-equipped NPWT unit. After the welcome call, the patient proactively initiated calls to the VTS in which concerns and technical issues were addressed, allowing the patient to remain adherent to therapy (8 nonadherent vs. 49 adherent days). One call placed by the patient facilitated communication between the home health nurse and the VTS. Afterwards, the nurse initiated 3 calls to the VTS, requesting assistance with dressing application techniques and troubleshooting.

Case 3: A 53-year-old woman was discharged home with a RTM-equipped NPWT unit to manage a dehisced surgical wound after a hysterectomy. The patient resumed work shortly after starting NPWT and the VTS advised her on how to discreetly manage NPWT in the workplace, which helped prevent nonadherence (0 nonadherent days).

Conclusions: In these 3 cases, RTM addressed the patients’ individual barriers to promote adherence to their NPWT treatment.

Information/Educational Report

Elaine H. Song, MD, PhD, MBA; Tiffany Hamm, BSN, RN, ACHRN, CWS; Jeff Mize, RRT, CHT, CWCA; Catherine T. Milne, APRN, MSN, CWOCN-AP; and Nataliya Lebendiskaya, RN, BSN, CWOCN

Background: In the outpatient setting, uncomplicated wound healing heavily depends on patient adherence to wound care plans. To fulfill their role, patients need to know several factors about products: how to purchase, where to obtain, their cost, and appropriate use.

Objective: This project aims to develop a solution for clinicians to quickly generate customized product handouts with clinical, coverage, pricing, and supplier information for patients.

Methods: Using Design Thinking methodology, the solution was developed as a module within a cloud-based clinical decision support platform for wound care and hyperbaric clinicians, as follows:

1. Wound care specialists’ needs and desired features were identified through interviews;
2. Prototype was developed with wireframing software then tested by specialists;
3. Module was developed using robust programming language, library, framework, and APIs (Medicare, others);
4. Module beta-tested at 5 wound clinics; feedback incorporated into the final product; and
5. Beta-sites completed validation survey.

Results: The final module instantly generates customized handouts for more than 900 wound care products across different brands. To generate a handout, the clinician chooses a product, enters the patient’s ZIP code, and selects the desired type of information. The handout is automatically populated with selected information, which may include product-specific description, Medicare coverage, copayment, local/online/preferred suppliers, pricing, and clinician’s notes; handouts can be printed, emailed, and bookmarked. Of the surveyed beta-users, 100% indicated they would use the module daily/weekly, and 80% indicated it meets their needs very well (vs. moderately or not as much).

Conclusions: A mobile-responsive solution that generates customized wound care product handouts with clinical, coverage, pricing, and supplier information has the potential to significantly increase patient adherence while saving the clinicians’ time.

Clinical Research

Robert Fridman, DPM, FACFAS, CWSP; Payam Rafat, DPM, AACFAS; Deena B. Horn, DPM, AACFAS; and Carl Van Gils, DPM, FACFAS, CWSP

Introduction: A majority of diabetic foot ulcers (DFUs) are refractory to standard of care. Many require treatment with advanced biologic products in an attempt to heal ulcers prior to developing worse complications. Patients who fail to respond to current standard of care advanced biologic products are left with poor clinical outcomes and increased health care spending.

Objective: The ability of a novel, decellularized, porcine-liver extracellular matrix (ECM) to treat failed or hard-to-heal DFUs is being prospectively assessed in a multicenter study.

Materials and Methods: Patients with a DFU between 1 cm² and 12 cm², present for at least 90 days, and following a minimum of 2 treatment attempts with advanced biologics were consented to participate following a 4-week washout period. Following consent, patients received standard of care for 2 weeks, followed by sharp debridement and treatment with the novel, decellularized, porcine-liver ECM. All patients received either a controlled ankle motion walker or offloading shoe with a customizable peg insert. The treatment phase lasted 12 weeks or until the wound healed as defined by 100% epithelialization, no exudate, and no need for dressing. Patients presented weekly for assessment, dressing change, and ECM reapplication as needed (no ECM material present in the wound and stalled wound healing).

Results: Majority of the 24 patients were male (66.7%), with a mean age of 62 years and a mean body mass index of 30.9. Four patients withdrew prematurely. The mean wound area was 3.4 cm² (range, 1.0 cm²–10 cm²) and mean ulcer age at treatment was 210 days (range, 91–1071 days). Patients had a median of 2 previous treatment attempts (2–13) with advanced biologics. Of the 24 patients enrolled, 11 healed within 12 weeks (55.0%) while 9 failed to achieve closure (45%). For patients whose wound healed, the mean time to closure was 7.2 weeks.

Conclusions: These favorable results are promising with healing rates at or above those seen with typical DFUs and other advanced biologics in this challenging patient population.

Case Series

Marcus Speyrer, RN, CWS; and Kerry T. Thibodeaux, MD, FACS

Background: Despite advances in perioperative care, operative technique, and understanding of risk factors, wound dehiscence remains a national health care quality concern such that it is one of the publicly reported outcome measures for the US Centers for Medicare & Medicaid Services. Early identification and appropriate management of wound dehiscence is key to reducing treatment costs. Standard of care includes debridement and regular cleansing/irrigation as needed, administration of culture-specific antimicrobials and/or antibiotics, protection of periwound tissue, and application of an appropriate dressing or therapy. Use of negative pressure wound therapy (NPWT) to help manage dehisced wounds has been reported in numerous studies with promising results. Patients with smaller, low-exudating dehisced wounds may benefit from ultraportable, mechanically powered disposable NPWT (dNPWT) that may allow a quick return to activities of daily living while receiving the effects of NPWT.

Objective: A retrospective data analysis was performed to determine outcomes of 4 patients with dehisced wounds that were adjunctively treated with dNPWT.

Materials and Methods/Results: Average age of patients was 63 years. Patients had undergone total knee arthroplasty, cyst removal, ankle open reduction internal fixation, or abdominoplasty prior to dehiscence. All wounds were debrided prior to dNPWT, and systemic antibiotics were administered in 2 of 4 patients. Disposable NPWT was applied to each wound with a foam dressing at -125 mm Hg and changed twice weekly. One wound was primarily closed after 90 days of dNPWT, and the remaining 3 healed via secondary intention after 41, 95, and 150 days of dNPWT.

Conclusions: Mechanically powered dNPWT was a convenient adjunctive therapy and resulted in positive outcomes for these 4 patients with dehisced wounds.

Information/Educational Report

Erin Tharalson, DNP, RN, ANP-BC, CWS; and Lynda Root, DNP, RN, PMHCNS-BC

Introduction: As the incidence of acute and chronic wound conditions rises and wound dressing protocols become more complex, uninsured patients lacking access to specialty wound care are challenged to manage their own wounds. Understanding multistep dressing change protocols may be inhibited by low health literacy. Low health literacy is associated with reduced disease knowledge and self-care. Little evidence of health literacy effects on wound patients and few literacy-sensitive educational interventions that address wound knowledge and self-care are available. Improved outcomes occur in all health literacy levels in other diseases with the use of literacy-sensitive educational interventions that incorporate more than one literacy strategy over multiple sessions.

Objective: To examine the effectiveness of a literacy-sensitive wound education intervention on wound knowledge and self-care, an evidence-based pilot project was conducted in an urban wound clinic.

Materials and Methods: A convenience sample of 21 patients received a literacy-sensitive wound education intervention consisting of spoken and written communication over several sessions. Instruments measured health literacy level, wound knowledge, dressing performance, and wound healing status.

Results: There was a significant increase in wound knowledge scores in all literacy groups from baseline to visit 2 (P<.01) and 4 (P<.01). Dressing performance scores remained consistently high through visit 4 in all literacy levels. All participants’ wounds progressed toward wound healing significantly from baseline to visit 2 (P<.01) and 4 (P<.01).

Conclusions: Incorporation of a literacy-sensitive education intervention with supportive literacy aids over several sessions supports improved wound knowledge and dressing self-care and can affect healing in patients of all health literacy levels.

These abstracts were not subject to the WOUNDS peer-review process.