The Clinical Signs and Symptoms Checklist is a tool designed to measure 12 clinical signs and symptoms of localized chronic wound infection. Since its initial development, this Checklist has been revised to include sanguineous drainage. To examine the inter-rater reliability of the revised Clinical Signs and Symptoms Checklist in diabetic foot ulcers, an observational, cross-sectional study was conducted in conjunction with a larger study examining the validity of each sign and symptom for identifying infection in diabetic foot ulcers. Two independent nurse observers assessed 64 diabetic foot ulcers in 64 patients using the Checklist. The reliability of each item was calculated using percent agreement and the Kappa coefficient. Total percent agreement ranged from 76% to 100%, and Kappa statistics ranged from .34 to 1.00. Study findings confirm that the Clinical Signs and Symptoms Checklist is a reliable tool for identifying the clinical signs and symptoms of localized infection in diabetic foot ulcers.
Abdominal wound disruption (AWD) is a postoperative complication that increases length of hospital stay, mortality, and cost. A retrospective cohort study was conducted to identify predictors of AWD, defined in the National Surgical Quality Improvement Program User Guide as a spontaneous reopening of a previously surgically closed (midline) wound that occurs within 30 days after index elective surgery in patients undergoing colorectal surgery. Data from the American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were searched, supplemented by institutional review board-approved chart review. Patients were identified using Current Procedural Terminology codes for open and laparoscopic abdominal colorectal procedures. Data were collected to predefined worksheets and entered into a statistical analysis program and included demographics; comorbidities; pre- and postoperative laboratory tests including white blood count, blood glucose, and albumin levels; date and type of procedure; wound classification; postoperative complication rate; type of access; time to disruption; surgical site infection (SSI); and use of the SSI intervention/prevention bundle. The Wilcoxon rank sum test was utilized to compare independent continuous variables between the groups, and Fisher's exact test was utilized to compare categorical variables. Variables with a P value <.2 at univariate logistic regression were included in multivariate logistic regression analysis. Time-to-event variables were compared using Cox regression analysis. Of the 690 patients included in the study, 16 (2.3%) developed an AWD. Mean age was 61.9 ± 15.3 years and 61.3 ± 15.0 years in AWD and non-AWD groups, respectively (P = .704). AWD occurred more frequently in men than women (75% vs. 50%; P = .040) and in patients who did compared to those who did not develop a deep incisional SSI (12.5% vs. 2%; P = .044). Preoperative albumin level was significantly lower in AWD (3.2 ± 0.8 vs. 3.8 ± 0.7; P = .006), as well as the proportion of post-bundle implementation (18.75% vs. 65.7%; P = .041). No significant differences were observed for any of the other variables examined. Per multivariate analysis, male gender (P = .05), absence of SSI bundle (P = .026), and hypoalbuminemia (P = .01) were independent predictors of AWD after elective colorectal resections. Time to AWD was significantly shorter in patients without SSI (P <.001). Results indicate implementation of the SSI bundle decreased AWD rates. Further prospective studies are needed to confirm these findings.
Despite advances in reconstruction techniques, ischial pressure ulcers continue to present a challenge for the plastic surgeon. The purpose of this retrospective study was to evaluate outcomes of using an oblique downward gluteus maximus myocutaneous (GMM) flap for coverage of grade IV ischial ulcers. Data regarding defect size, flap size, operation time, duration of wound healing, and surgical outcome were abstracted from the medical records of patients whose ischial pressure ulcers had been reconstructed using GMM island flaps between January 2010 and December 2015. The 22 patients comprised 15 men and 7 women with a mean age of 52 (range 16-81) years. Twenty (20) had paraplegia, 6 had a recurrent ischial ulcer, 2 were bedridden following a cerebrovascular accident, 1 had a myelomeningocele status post operation, and 19 were spinal cord injury patients. Follow-up time ranged from 6 to 40 months. Pressure ulcer size ranged from 3 cm x 2 cm to 10 cm x 5 cm (average 22.3 cm(2)). The average flap size was 158 cm(2) (15.9 cm x 9.7 cm); the largest was 286 cm(2) (22 cm x 13 cm). The operating time ranged from 52 minutes to 110 minutes (average, 80 minutes). In 2 cases, wound dehiscence occurred but completely healed after resuturing. One (1) ischial pressure ulcer recurred 6 months following surgery and was successfully covered with a pedicled anterolateral thigh flap. No recurrences or problems were observed in the remaining 20 patients. Time to complete wound healing ranged from 14 to 24 days (average 17.8 days). Treatment of ischial pressure ulcers with GMM flaps allowed for an easy, simple procedure that provided the adequate thickness of soft tissue needed to cover the bony prominence, fill dead space, and cover the lesion. This technique was a reliable and safe reconstructive modality for the management of ischial pressure ulcers, even in recurrent cases.
Pressure ulcers (PUs) are detected by visual skin assessment (VSA). Evidence suggests ultrasound (US) and subepidermal moisture (SEM) scanner technology can measure tissue damage before it is visible.PURPOSE:A pilot study was conducted to evaluate consistency between SEM and US examinations of suspected deep tissue injury (sDTI).METHOD:Using an observational, prospective cohort study design, patients >55 years of age were recruited. VSA, SEM, and US assessments were performed daily for a minimum of 3 and maximum of 10 consecutive days following enrollment. US results were considered indicative of sDTI if hypoechoic lesions were present. SEM readings were considered abnormal when ∆ ≥0.6 was noted for at least 2 consecutive days. Boolean analysis was utilized to systematically determine consistency between US and SEM where sDTI was the clinical judgment.RESULTS:Among the 15 participants (10 women, mean age 74 ± 10.9 years), there was consistent agreement between SEM and US when sDTIs existed. For 1 patient who developed a heel sDTI during the study, SEM readings were abnormal 2 days before VSA indicated tissue damage and 3 days before the appearance of a hypoechoic lesion in the US.CONCLUSION:US and SEM results were similar, and in an evolving sDTI case, SEM detected a lesion earlier than US.
Management of diabetes-related foot ulcers often involves debridement of devitalized tissue, but evidence regarding the most effective debridement method is limited. Purpose: A systematic review was conducted to determine the effectiveness of nonsurgical sharp debridement (NSSD) versus low-frequency ultrasonic debridement (LFUD) for diabetes-related foot ulceration in adults. Method: Published studies (earliest date available to April 2017) comparing healing outcomes of LFUD- and NSSD-treated foot ulcers in adults were considered. The quality of publications that met inclusion criteria were assessed using the PEDro scale, and a meta-analysis was undertaken to compare percentage healed and percentage of ulcer size reduction. Results: Of the 259 publications identified, 4 met the inclusion criteria but 2 of the 4 did not contain sufficient patient outcomes details for meta-analysis, leaving a sample size of 173 patients. Outcome data for the 2 studies included percentage of ulcers healed between the 2 debridement methods. This difference was not significant (RR = 0.92; 95% CI = 0.76-1.11). The risk of bias for both studies was low. Conclusion: No difference in healing outcomes between NSSD and LFUD debridement of diabetic foot ulcers was found. Well-designed, controlled clinical studies are needed to address the current paucity of studies examining the efficacy and comparative effectiveness of debridement methods.
Little is known about the nutritional status and dietary habits of persons with an intestinal stoma, and no specific dietary guidelines have been established. A cross-sectional study was conducted among patients of a Stoma Patient Health Care Service in Juiz de Fora, Brazil, to compare the nutritional status of persons with an ileostomy or colostomy and to evaluate which foods are avoided most frequently and why. Anthropometric measurements (weight, height, arm circumference, and triceps and subscapular skinfold thickness) and body fat were assessed. Habitual dietary intake (energy, protein, carbohydrate, fiber, fat, calcium, iron, sodium, potassium, thiamin, riboflavin, vitamin B6, vitamin B3 [niacin], and vitamin B12) was assessed using a validated quantitative food frequency questionnaire. Foods avoided and reasons for avoidance (increased odor, increased gas, increased output, constipation, appliance leakage, and feelings regarding leaving home) were assessed. All data were collected without personal identifiers and stored in electronic files. Data were analyzed descriptively, and the Student's t test or Mann-Whitney test was used to compare the groups. Chi-squared analysis with Yates' continuity correction or Fisher's exact test was employed to examine the differences in the frequency of avoided foods by reasons for avoidance between the 2 groups. Of the 103 participants (52 [50.5%] men, 51 [49.5%] women; mean age 60.5 ± 12.9 years); 63 (61.2%) had a colostomy and 40 (38.8%) had an ileostomy. For both groups combined, time since surgery ranged from 1 to 360 months. Anthropometric measurements and body composition did not suggest nutritional deficiencies and did not differ significantly between groups. Persons with an ileostomy had a significantly lower fat and niacin intake than persons with a colostomy (P <.05). No other dietary intake differences were observed. Avoiding foods due to appliance leakage was more common among participants with an ileostomy (8, 20%) than a colostomy (3, 4.8%), and vegetables and fruits were reported as the most problematic foods. None of the other cited reasons was significantly different. The results of this study confirm that many persons with a stoma adjust their dietary intake and avoid certain foods which, especially in persons with an ileostomy, may increase their risk for nutritional deficiencies. Additional research to assess dietary intake and nutritional status variables as well as patient needs is needed to facilitate the development of specific nutritional status monitoring and dietary recommendations for persons with an ileostomy or colostomy.
Incontinence-associated dermatitis (IAD) is a common, painful, difficult-to-treat skin condition.PURPOSEA 2-part, quasi-experimental, post-test study was conducted to evaluate the impact of prevention initiatives on IAD prevalence and incontinence practices.METHODIn part 1, from May 2017 to November 2017, a quasi-experimental post-test study design was conducted in a health district in Australia. Following an audit of IAD prevalence and identification of evidence practice gaps in 4 hospitals in a local health district (12 wards, 250 patients), an implementation science approach was used to implement evidence-based initiatives. An IAD committee was formed, staff were educated about correct incontinence pad sizing, washable and disposable underpads and plastic sheets were removed from the care setting, and barrier cream cloths for cleansing, moisturizing, and protecting skin were introduced. Patients admitted to 1 of the 12 wards who were ≥18 years of age were recruited for participation and evaluation in the post-intervention implementation IAD and incontinence care practices audit. Post-intervention data were entered into a software program and compared to pre-implementation data using descriptive and bivariate statistics. In part 2, nurses from the 12 wards were asked to participate in 1 of 6 focus groups to share their impressions about the barrier cream cloths. Discussions were transcribed verbatim and analyzed using descriptive content analysis.RESULTSThe rate of incontinence among audited patients (N= 259, 132 men, 124 women; mean age 73.2 ± 16.8 years) was 47.2% (119/252) and 2/259 (0.8%) had a pressure injury (PI). IAD prevalence was significantly lower in the post- than in the pre-implementation audit (6/259 vs 23/250, P = .015), as was hospital-acquired pressure injury (9/250 [3.6%] vs 2/259 [0.08%]) and the use of bed protection layers (154/238 vs 6/259; P <.01). The focus groups included 31 nurses (25 women, 6 men). Four (4) themes emerged: 1) benefits to the patient (eg, improved skin condition), 2) usability (eg, fewer steps), 3) problems encountered (eg, not seeing the barrier in place), and 4) related factors. Patient comfort was cited frequently as an important benefit.CONCLUSIONEvidence-based initiatives led to a significant reduction in IAD prevalence and improved incontinence care practices. .
PURPOSE Because infection can thwart burn healing, microorganisms, their susceptibility patterns, and the effect of tangential excision timing on outcomes of burn patients were examined. METHODS A prospective, observational study was conducted that involved 318 patients with deep second-degree burns from a gas explosion treated in Xinxiang, Henan, China between January 2009 and December 2016. Patient demographic data, culture and antimicrobial susceptibility test results, and outcome variables (resuscitation fluid volume, signs of shock, body temperature, heart rate, and time to wound healing) were analyzed. Outcomes were compared among patients who had early (<24 hours), middle (2 to 7 days), and late (> 7 days) post burn excision. RESULTS Bacterial culture and drug sensitivity data were available for 314 of the 318 persons with burns >10% of total body surface area (TBSA). Of the 486 bacterial isolates, 330 (67.9%) were gram-negative and 156 (32.1%) were gram-positive. The number of isolates and resistance to third-generation cephalosporins increased over time. Patients having early tangential excision had significantly lower heart rate (P <.05) and reduced time to healing (P <.01) than patients in the middle or late excision group. CONCLUSION Early tangential excision was found to be safe and to facilitate healing.
Three-dimensional (3D) printing technology can generate objects in almost any shape and geometry. This technique also has clinical applications, such as the fabrication of specific devices based on a patient's anatomy. A demonstration study is presented of a 54-year-old man who needed a thermoplastic splint to limit arm movement while a dehisced left shoulder wound healed. The patient's upper extremity was scanned using the appropriate noncontact scanner and 3D technology software, and the polylactic acid splint was printed over the course of 66 hours. This patient-specific splint was worn during the day, and after 2 weeks the wound was healed sufficiently to permit hospital discharge. Creation of an individualized splint is one of many potential medical uses of 3D technology. Although the lengthy printing time imposes limitations, the implications for practice are positive.
The use of electrical stimulation (ES) should be considered for treating nonhealing pressure ulcers (PUs), but optimal ES wound treatment protocols have yet to be established. A randomized, controlled, double-blind clinical study was conducted to evaluate the effects of cathodal and anodal high-voltage monophasic pulsed current (HVMPC) on periwound skin blood flow (PSBF) and size reduction of Stage 2 to Stage 4 PUs of at least 4 weeks' duration. Persons >18 years of age, hospitalized with neurological injuries, at high risk for PU development (Norton scale <14 points; Waterlow scale >15 points), and with at least 1 Stage 2 to Stage 4 PU were eligible to participate in the study. Persons with necrotic wounds, osteomyelitis, electronic or metal implants in the PU area, PUs in need of surgical intervention, acute wound inflammation, diabetes (HBA1c >7%), diabetic neuropathy, cancer, and/or allergies to standard wound treatments were excluded. Patients were randomly assigned to 1 of 3 groups: anodal (AG), cathodal (CG), or placebo (PG) ES. All groups received individualized PU prevention and standard wound care. In the PG, sham ES was applied; the AG and CG were treated with anodal and cathodal HVMPC, respectively (154 μs 100 Hz; 360 µC/second; 1.08 C/day), 50 minutes per day, 5 days per week, for a maximum of 8 weeks. PSBF was measured using laser Doppler flowmetry at baseline, week 2, and week 4, and wound surface area measurements were obtained and analyzed using a digitizer connected to a personal computer. Data analysis utilized the maximum-likelihood chi-squared test, the analysis of variance Kruskal-Wallis test, the Kruskal-Wallis post-hoc test, and Spearman's rank order correlation. Nonlinear approximation based on exponential function was used to calculate treatment time needed to reduce the wound area by 50%. In all tests, the level of significance was set at P ≤.05. Of the 61 participating patients, 20 were in the AG (mean age 53.2 ± 13.82 years), 21 in the CG (mean age 55.67 ± 17.83 years), and 20 in the PG (mean age 52.5 ± 13.18 years). PUs (baseline size range 1.01 cm2 to 59.57 cm2; duration 4 to 48 weeks) were most frequently located in the sacral region (73.77%) and classified as Stage 3 (62.29%). PSBF at week 2 was significantly higher in the AG and CG than in the PG (P <.05). Week 4 differences were not statistically significant. Wound percentage area reduction calculated at week 8 for the AG (64.10% ± 29.22%) and CG (74.06% ± 23.23%) were significantly different from PG ulcers (41.42% ± 27.88%; P = .0391 and P = .0024, respectively). In both ES groups, PSBF at week 4 and percent wound surface area reductions between weeks 4 and 8 were positively correlated, but only the AG correlation was statistically significant (P = .049). In this study, both ES modalities improved blood flow and wound area reduction rate. Studies examining optimal ES treatment times for healing to occur, the effect of comorbidities and baseline wound variables on ES outcomes, and the nature of the relationship between blood flow and healing are necessary.
Adenocarcinoma that occurs at the ileostomy site after proctocolectomy (TPC) with an end ileostomy for ulcerative colitis (UC) and/or familial adenomatous polyposis (FAP) is a late and uncommon complication. To ascertain the rate of adenocarcinoma at the empirical ileostomy site following TPC, a review of the literature was conducted. PubMed, MEDLINE, the Cumulative Index of Nursing and Allied Health Literature, EMBASE, Google search engine, and the Cochrane Database were investigated for research published between January 1975 and December 2016. Search criteria included English language and human-only publications; broad search terms related to UC, FAP, ileostomy procedures, and dysplasias were used. Abstracts were eliminated if they were foreign language and nonhuman studies; editorials also were excluded. Secondary and hand/manual searches of reference lists, other studies cross-indexed by authors, reviews, commentaries, books, and meeting abstracts also were performed. Data extracted included age at diagnosis, operation technique, interval to ileostomy cancer, age when cancer was diagnosed, histology for both UC and FAP patients, and subsequent treatment. Papers were included on the basis of available evidence for each specific point of interest. Final and conclusive agreement was assessed with the k statistics during the title review and abstract review. Studies that did not report original data also were excluded. A total of 5753 publications were identified; 5697 publications did not conform to inclusion criteria and were eliminated. Among the reviewed publications (all case studies), 57 patients were diagnosed with ileostomy adenocarcinoma after TPC; 42 had UC, and 15 had FAP. The interval between TPC operation and ileostomy cancer diagnosis ranged from 3 to 51 years for UC and from 9 to 40 years for FAP, with a mean interval of 30 and 26 years, respectively. Biopsies were performed of all polypoid lesions found at the stoma site. Patients were treated with wide excision and refashioning (diversion) of the stoma. While adenocarcinoma arising at the mucocutaneous junction at the ileostomy site with adjacent skin invasion after TPC for UC and FAP appears to be rare, patients and clinicians need to be aware of this potential complication even years after surgery and regular screening is recommended.
Hospital-acquired pressure injuries (PIs) present a significant challenge to pediatric providers.PURPOSE:The purpose of this quality improvement program was to develop and implement a debrief protocol and to evaluate compliance with and the implementation of a comprehensive prevention bundle to decrease the overall incidence and severity of pediatric pressure ulcers (PUs)/PIs in a free-standing children's hospital.METHODS:As a member of the Children's Hospitals Solution for Patients Safety national network, a PU Hospital Acquired Conditions (HAC) team was created in 2013, followed by the development and implementation of a PU occurrence debrief tool and discussion guide and implementation of multiple staff educational strategies and a comprehensive prevention bundle. The PU occurrence debriefing occurred within 24 to 48 hours of a PU. Incidence data were collected annually from 2014 until 2017.RESULTS:Compliance on implementation and documentation of bundle elements ranged from 88% to 94%, and PU/PI incidence decreased by 30% from 2014 to 2016 and by 40% in 2017. The overall PU rate was 0.0057 in 2014, 0.0050 in 2015, 0.0036 in 2016, and 0.0023 in 2017; 65% of all PUs were device-related. Of those, >50% were related to respiratory devices, 25% to peripheral intravenous catheters/central lines, 10% to tracheostomies, and 15% to other devices. Respiratory device-related PUs decreased by 50% in the pediatric intensive care unit, by 80% in the neonatal unit, and eliminated completely in extracorporeal membrane oxygenation patients.CONCLUSION:The debriefing process, debriefing tool, educational programs, and prevention bundle reduced the rate of hospital-acquired PIs in pediatric patients and propagated a culture of safety.
The challenges of managing Gustilo IIIB tibial fractures (ie, high energy trauma with a contaminated wound >10 cm in length, severe comminution ["crumbling"] or segmental fractures, and periosteal stripping) in children are unique in part because no clear guidelines exist and the injuries may cause short-term and long-term complications. Repeated wound debridement and secondary reconstruction are required in approximately 20% of these cases in both adults and children. A 13-year-old girl presented with severe polytrauma including an open Gustilo type IIIB fracture of the left lower leg. The patient declined limb amputation; a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeons, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) was assembled in order to give the patient the best chance of a successful outcome. Multiple limb salvage and reconstructive procedures including wound debridements, necrectomies, long-term negative pressure wound therapy, soft tissue reconstructions, external bone fixation, bone osteosynthesis, multiple skin grafts, and free-flap reconstruction were provided over a period of 6 months with great success. The patient is doing well 3 years after initial injury and is walking without complications. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, decrease morbidity, and provide the patient with the best result possible. Studies examining optimal treatment strategies for children and adolescents with these complicated fractures are needed.
Topical silver agents and dressings are used to control infection and promote healing in chronic wounds, but reviews published from 2006 to 2011 found heterogeneous results regarding their effectiveness. A scoping review was conducted to examine the extent, range, and nature of research activity surrounding chronic wound care that employed silver-impregnated dressings; identify research gaps in the existing literature; and summarize the evidence to provide recommendations for future clinical studies. Ten (10) electronic databases and additional sources were screened from their inception to May 2016; search terms for the different databases included but were not limited to silver, chronic, complications, wound, ulcer, and sore. English-language articles that compared silver dressings with an alternate treatment in adults with chronic wounds and that reported clinical outcome measures were included. Of 222 full-text reviewed studies, 27 were included for qualitative analysis. Qualitative analysis was guided by key findings identified among the included studies that were analyzed in aggregate form where appropriate. In comparative analyses of the 26 studies that investigated wound healing, 15 revealed significantly positive wound healing outcomes with silver treatments versus 9 that did not; the remaining 2 failed to provide statistical values of significance. Of 17 studies that presented data on microbiology, 3 reported significant microbial load improvement for silver dressings, 9 noted nonsignificant findings, and 4 provided no statistical values. Pain, adverse events, and treatment cost were included in 5, 7, and 3 studies, respectively, with heterogeneous findings. The heterogeneous evidence regarding the impact of silver dressings on clinical outcomes may be related to differences in the silver treatments themselves, heterogeneous intervention strategies, study designs, outcomes, and measures. Well-designed clinical studies with multiple outcome parameters are necessary to determine the optimal type and use of silver-dressings in chronic wounds.
Care of the patient with an ostomy is included in the curriculum of prelicensure nursing programs, but no studies examining student nurses' knowledge about stoma care have been published. The purpose of this project was to examine the ostomy knowledge, experiences, and confidence of nursing students in order to assess and improve the curriculum. At the end of the fall 2016 semester, students enrolled in 3 separate nursing courses in an undergraduate program were asked to participate in a project to examine students' ostomy knowledge, their experiences, and their confidence in providing care. This project was undertaken to explore the college's ostomy curriculum. Participation was voluntary, and no student who was willing to participate was excluded. Students completed a 50-question knowledge test, answered questions about the frequency of performing ostomy-related skills, and rated their confidence in providing ostomy care. Responses were examined with descriptive and inferential statistics. Of 189 possible participants, 138 completed the questionnaires and included mostly women (113, 81.9%); participant mean age was 27.26 ± 6.22 years. The mean number of correct knowledge responses was 35.66 (71.32%); 66 participants (47.8%) reported no experience caring for a patient with an ostomy. The most common skills performed in clinical rotations were emptying (49) and changing (24) the pouch. A scale of 1 to 5 was used to evaluate 6 confidence items, with students having a mean confidence score of 19.54 ± 5.20. They had the most confidence in their ability to empty a pouch and to size and fit the pouching and the least confidence in teaching and community resources. Confidence was related to the number of skills performed in the lab (r = .32; P <.001), the number of skills performed in clinical practice (r = .38; P <.001), and ostomy knowledge scores (r = .23; P <.007). Total correct knowledge scores did not differ significantly by year in the educational program. Based on the results of this survey, it was concluded that students had a beginning knowledge about ostomy care and very limited clinical experience, yet confidence in providing ostomy care was high. Curriculum adjustments were implemented, including strategies for increasing ostomy knowledge, opportunities to provide care, and confidence; these need further investigation in prelicensure undergraduate nursing programs. The effect of curriculum adjustments remains to be evaluated.
Many recent studies have focused on the potential role of topical agents in the wound healing process. To compare the time to healing of full-thickness wounds treated with topical estrogen, phenytoin, or silver sulfadiazine (SSD), an in vivo study was conducted using 32 male Wistar rats. Animals were housed individually in standard cages in similar environmental conditions, and a single, circular (4 mm in diameter), full-thickness skin wound was created on the dorsum of each rat. Animals were randomly divided into 4 groups of 8 rats each and treated with topical phenytoin, SSD, estrogen cream, or no treatment/control. Each wound was measured and examined daily until healing, defined as complete reepithelialization and closure of the wound. Group mean healing times were calculated, and Tukey's multiple comparison test was used to compare these data. Average times to healing were 11 days in estrogen group, 10 days in phenytoin group, 7.62 days in SSD group, and 11.87 days in control group. Wound healing was significantly faster in the SSD compared to control (P <.01) and the estrogen group (P <.01). No other differences were statistically significant. Further studies, especially randomized clinical trials on human beings with larger sample sizes, are recommended to elucidate if these topical agents affect wound outcomes.
The sacral area is the most common site for pressure injuries (PIs) associated with prolonged supine bedrest. In previous studies, an anisotropic multilayer prophylactic dressing was found to reduce the incidence of PIs and redistribute pressure. The purpose of the current study was to further investigate relationships between design features and biomechanical efficacy of sacral prophylactic dressings. Using computer modeling, the anisotropic multilayer dressing and a hypothetical dressing with different mechanical properties were tested under dry and 3 levels of moist/wet conditions. Sixteen (16) finite element model variants representing the buttocks were developed. The model variants utilized slices of the weight-bearing buttocks of a 28-year-old healthy woman for segmentation of the pelvic bones and soft tissues. Effective stresses and maximal shear stresses in a volume of interest of soft tissues surrounding the sacrum were calculated from the simulations, and a protective endurance (PE) index was further calculated. Resistance to deformations along the direction of the spine when wet was determined by rating simulation outcomes (volumetric exposures to effective stress) for the different dressing conditions. Based on this analysis, the anisotropic multilayer prophylactic dressing exhibited superior PE (80%), which was approximately 4 times that of the hypothetical dressing (22%). This study provides additional important insights regarding the optimal design of prophylactic dressings, especially when exposed to moisture. A next step in research would be to optimize the extent of the anisotropy, particularly the property ratio of stiffnesses (elastic moduli).
Peristomal skin problems represent one of the most common complications of a tracheostomy. A quasi-experimental study was conducted among patients ages 18 to 65 years hospitalized in a Turkish university hospital ear-nose-throat clinic between August 15, 2013, and December 15, 2013, to compare the effect of using or not using a barrier cream on the peristomal skin with regard to pH, moisture, temperature, color, odor, turgor, infections, and lesions after tracheostomy surgery. Patients were selected using a purposeful sampling method and included if they had not undergone another operation for a complication (eg, pneumothorax, tube misplacement, hemorrhage) within 24 hours following the tracheostomy operation. In phase 1 of the study, 9 registered nurses were observed 3 times each by the researcher, who completed an observation form. From these observations and related nursing textbooks, the researcher developed a protocol entitled "Nursing Care Steps for Patients with a Tracheostomy." This protocol was followed during phase 2 of the study during which participants were alternately assigned to either the intervention (a barrier cream containing dimethicone, acrylate terpolymer, oils, paraffin, water, dicapryladipate, isopropyl palmitate, and PPG-15 stearyl ether followed by gauze) or control (gauze only) group (n = 30 each) and observed for 7 days. Demographic characteristics were gathered for each patient upon admission to the study. Peristomal skin was assessed in terms of pH, temperature, and moisture (relative humidity [RH]) using a surface pH meter, surface thermometer, and digital skin moisture tester, as well as for lesions, infection, and maceration. Findings were documented on a skin condition assessment form. Twenty-four (24) hours post surgery, the barrier cream plus gauze was applied over peristomal area in the study group and gauze dressing only in the control group. Peristomal skin pH, moisture, and temperature were within the normal range for both groups during all observations throughout the study but closer to normal ranges in the intervention group. Mean peristomal skin pH in the intervention group was significantly higher (5.452 ± 0.043) than in the control group (5.123 ± 0.057; P &.001), mean peristomal skin moisture in the control group (46.90 ± 0.132 RH) was significantly greater than in the intervention group (41.71 ± 0.774 RH; P &.001), and mean peristomal skin temperature in the control group (33.59 ± 1.3˚ C) was significantly higher than in the intervention group (31.64 ± 0.607˚ C; P &.001). In both groups, Staphylococcus epidermidis was the most commonly cultured microorganism, and S aureus was the most cultured pathological microorganism in addition to the normal skin flora. Peristomal skin condition was maintained for both the intervention and control groups. Use of a barrier cream to protect tracheostomy peristomal skin beneath absorbent dressings (eg, gauze) is recommended, but additional short-term and long-term studies are needed.
Patients with a hip fracture are at high risk for pressure injury. A retrospective review of the electronic medical records of consecutive patients with a hip fracture treated in 2016 in a single tertiary hospital in east China were examined to investigate whether time of year affected the incidence of hospital-acquired pressure injury. Data collected included demographic characteristics (patient name, hospital number, age, gender, and body mass index); possible risk factors for pressure injury, such as presence of diabetes mellitus, admission hemoglobin, admission albumin, length of surgery, and the lowest and/or last Braden Scale score before pressure injury developed; and pressure injury information, which included time of occurrence (days after surgery), location (sacrum and coccyx, ischial tuberosity, or heel), stage, and treatment outcome. Pressure injury incidence was calculated with 95% confidence intervals (CIs) in each month and season (spring, summer, autumn, and winter). Odds ratios (ORs) and 95% CIs were calculated as estimates of risk. Multivariate logistic regression was used for risk factors. Of the 235 patients with a hip fracture included in the study, 95 (40.4%) were male, 140 (59.6%) were female, and mean age was 70.4 ± 10.5 (range 48-81) years. Thirty-one (31) patients (13.2%, 95% CI 9.1%-18.2%) developed 37 pressure injuries, 30 of which (81.1%) were Stage 1. The incidence of pressure injury was lowest in November (5.0%; 95% CI: 0.0%-24.9%) and highest in June (22.7%; 95% CI: 7.8%-45.4%). Average Braden Scale scores (14.2 ± 3.2) were lower in June than in November (16.6 ± 3.5), owing to differences in the Braden Scale skin moisture subscale. Seasonally, the incidence of pressure ulcers was 20.8% (95% CI: 12.2%-32.0%) in the summer compared to 7.5% (2.5%-16.6%) in autumn (crude OR 3.3; 95% CI:1.0-12.1; P = .025). Multivariate logistic regression analysis showed the Braden Scale score was the only independent risk factor (P <.05) for pressure injury incidence. Adjusting for the Braden score, the OR of summer season was 1.537 (95% CI: 0.964-2.872). The findings suggest that humidity and temperature levels, which are very high in the summer in China, may affect pressure injury incidence and that the Braden Scale score - especially the skin-moisture level subscore - is a valid predictor of pressure injury risk in this population. While more research is needed, additional pressure injury prevention strategies should be provided for patients hospitalized with a hip fracture in the summer months.
