Wound Care: What the Medical Director Needs to Know

Wound Literature Review 2010

Significance: The increasing complexity of medical and surgical care provided to pediatric patients has resulted in a population at significant risk for complications such as pressure ulcers, nonhealing surgical wounds, and moisture-associated skin damage. Wound care practices for neonatal and pediatric patients, including the choice of specific dressings or other wound care products, are currently based on a combination of provider experience and preference and a small number of published clinical guidelines based on expert opinion; rigorous evidence-based clinical guidelines for wound management in these populations is lacking. Recent Advances: Advances in the understanding of the pathophysiology of wound healing have contributed to an ever-increasing number of specialized wound care products, most of which are predominantly marketed to adult patients and that have not been evaluated for safety and efficacy in the neonatal and pediatric populations. This review aims to discuss the available data on the use of both more traditional wound care products and newer wound care technologies in these populations, including medical-grade honey, nanocrystalline silver, and soft silicone-based adhesive technology. Critical Issues: Evidence-based wound care practices and demonstration of the safety, efficacy, and appropriate utilization of available wound care dressings and products in the neonatal and pediatric populations should be established to address specific concerns regarding wound management in these populations. Future Directions: The creation and implementation of evidence-based guidelines for the treatment of common wounds in the neonatal and pediatric populations is essential. In addition to an evaluation of currently marketed wound care dressings and products used in the adult population, newer wound care technologies should also be evaluated for use in neonates and children. In addition, further investigation of the specific pathophysiology of wound healing in neonates and children is indicated to promote the development of wound care dressings and products with specific applications in these populations.

35 Years of Advances in Skin & Wound Care: Celebrating the Evolution of the Wound Care Team.

Medical Director, CPGs Spell QI Success

Evidence-Based Medicine in Wound Care

The adverse impact of chronic wounds is felt worldwide. The concerns for advanced wound care product are progressively increasing due to factors such as value for money spent in wound care products. Acute and Chronic wounds are managed in most health facilities in Ghana with sodium chloride (0.9%) infusion solution and povidone iodine fortified with metronidazole solution. The procedure is usually done by the nurse cleaning the wound with the saline solution wet gauze or cotton and then covered with the povidone iodine wet gauze for acute and chronic wounds. For chronic infected wounds, the wound is usually cleaned with saline solution and covered with wet gauze saline or currently with neomycin wound care spray or powdered antibiotics applied on the wounds. But it is popular as many wounds are covered with povidone iodine after wound cleaning in wound care practices in Ghana. Despite all these efforts, many wounds, especially chronic type wounds take a very long time to heal or sometimes fails to heal which reduce the quality of life of the people suffering from the menace. When it happens in this way, many resort to the use of local remedies to cause the wounds to heal but no avail, especially in Ghana where advanced treatment is scare. It is against this background that focal research in wound care was done in Ghana to come out with an innovative pharmaceutical wound care product effective for chronic and acute wounds healing to improve the quality of life of people as global burden of wounds escalates. In a Blind Observational Study for a period of five years in Ghana to observe the wound care products efficacy to heal wounds especially chronic types, the objective of the study was to examine a new product efficacy in chronic wound healing in the targeted population of patients with wounds. A product that has dual purpose of wound care as a cleaning and application agent, also has unique product pharmaceutical characteristics. A scalable, easy- to- use, multi-purpose, multi-use and cost-effective product, able to address the barriers or problems of wounds healing. The areas of consideration as far as wound care are concerned included: The study also sought to observe the product ability to control wound pains, control wound bleeding, control and prevent wound infection, remove wound debris, remove wound exudates effecting wounds healing at reduced healing time and with minimal scar in varied targeted patients’ population. Again, to observe the product with outcome of which to mitigate the long-term effect of chronic wounds like recurrent hospitalizations, financial burden, amputations, deformity, and frequent visit to hospital for wound care. One product, 9G Wound Solution (a cleaning and application product) manufactured by Pat J Health Company Limited, Ghana, was effective in wounds healing, especially, effective chronic wounds healing. The product was used to subject varied patients’ population with wounds on randomized basis, for wound care, and through observation the direct short, intermedial and long-term outcomes recorded of product effectiveness recorded. The outcome reported included control of wound pains, control of wound odor, control of bleeding, control of wound infection, removal of wounds exudates, removal of wound debris and ultimately reduced wound healing time to prevent wounds complications like amputations. The study was progressively extended across 10 regions in Ghana to cover 500 patient population with varied wounds. Patients’ population included those with Diabetic ulcers, Burns, pressure ulcers, venous ulcers, herpes zoster skin ulcers, Perineum wounds, Surgical abdomen-pelvic wounds, Traumatic wounds, Buruli Ulcers, gas gangrene wounds, and Mouth ulcers. The outcome of using the new wound care product were directly observed for the study period. By this observational study, the new product was observed to be superior to the controls as this product was able to heal 99% patients who had wounds, especially chronic wounds for many years, including 20years-old wound at reduced healing rate with no reoccurrence within the study period. The product scientifically readily released to the wound environment modulators capable to address the problems or barriers of wounds and simultaneously promoting modulators effective for wound healing. The product was not only effective in chronic wound healing at reduced time but also controlled wound pains shortly, controlled wound odor shortly, stopped wound bleeding, fought and controlled wound infection. However, using the product needed change of wound dressing every two days. The long-term effect of the product on target population not conclusively observed within the period of the research. We need to continuously observe the reported long-term effect of the product efficacy.

The Medical Director Should Be a Teacher

Palliative Wound Care for PALTC

Three Wound Care Quality Performance Measures Are Now Public: Why It Matters

Say Goodbye to Wet-to-Dry Wound Care Dressings

History, Current Practice, and the Future of Wound Care for Occupational and Physical Therapists.

Quality Indicators for Assessing Care of Vulnerable Elders16 October 2001Quality Indicators for Prevention and Management of Pressure Ulcers in Vulnerable EldersFREEBarbara M. Bates-Jensen, PhD, RN, CWOCNBarbara M. Bates-Jensen, PhD, RN, CWOCNFrom University of California, Los Angeles, Los Angeles, California; and the Borun Center for Gerontological Research, Los Angeles, California.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-135-8_Part_2-200110161-00014 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Pressure ulcers can lead to pain, disfigurement, and slow recovery from comorbid conditions. They interfere with activities of daily living, predispose to osteomyelitis and septicemia (1), and are strongly associated with longer hospital stays and mortality. Frailty and chronic illness, both common among older adults, predispose to pressure ulcers (1–3).The prevalence of pressure ulcers is 10% to 14% among hospitalized patients of all ages (4, 5) and up to 24% among patients in nursing homes (2). One goal of Healthy People 2010 is to reduce the prevalence of pressure ulcers in nursing home patients by 50% (6). Prevention and treatment of pressure ulcers are an important aspect of care for vulnerable elders. This paper presents quality indicators for the prevention and care of pressure ulcers among vulnerable elders and the evidence supporting these indicators.MethodsThe methods for developing these quality indicators, including literature review and expert panel consideration, are described in detail in another paper in this issue (7). For pressure ulcers, the structured literature review identified 177 titles, from which abstracts and articles that were relevant to this report were identified. Fifteen potential quality indicators were proposed on the basis of the literature and the author's expertise and files from previous reviews of the subject (8, 9).ResultsOf the 15 potential quality indicators, 10 were judged to be valid by the expert panel and 1 additional indicator was created by the panel (see the quality indicators). One indicator was merged with an accepted indicator, and 4 were not accepted. The literature supporting each of the indicators judged to be valid by the expert panel process is reviewed below.Quality Indicators 1 and 2: Pressure Ulcer PreventionRisk AssessmentIF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment for pressure ulcers should be done on admission BECAUSE risk assessment can predict pressure ulcer formation in such high-risk groups and forms the basis for intervention.Positioning Needs and Pressure ReductionIF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk, THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours BECAUSE reduction or elimination of risk factors can prevent pressure ulcer formation.Supporting Evidence. Several cohort and prospective studies and various expert groups provide evidence supporting timely risk assessment. Braden and Bergstrom (10) studied the predictive validity of risk assessment for pressure ulcers in 102 newly admitted nursing home residents. Using the Braden Scale (Figure) with a cutoff score of 18, they demonstrated that the sensitivity, specificity, positive predictive value, and negative predictive value of the admission assessment for subsequent development of pressure ulcers were 75%, 59%, 41%, and 86%, respectively. Of the 28 residents who developed pressure ulcers, the ulcer developed within about 2 weeks after admission in 71%, and all ulcers developed less than 4 weeks after admission (10).Figure. The Braden Scale for predicting risk for pressure ulcers. Download figure Download PowerPoint A multisite cohort study of 843 patients who were followed for 4 weeks found that the Braden Scale was predictive of pressure ulcer development in tertiary care centers, Veterans Affairs medical centers, and skilled nursing facilities (11). As part of the study, prescription of preventive interventions for turning and pressure reduction were evaluated in all three health care settings. Regardless of setting, turning schedules and pressure reduction were prescribed less frequently (7.7% and 34%) for patients at no risk or low risk (Braden Scale scores ≥ 16) than for patients at moderate or high risk (Braden Scale scores ≤ 15; 51% and 69%) (12). In another prospective cohort study of 200 newly admitted nursing home residents, the best predictor of all stages of pressure ulcer formation was Braden Scale score (13). Other investigators also found an association between preventive interventions and Braden Scale scores, in particular the subscale scores for mobility, friction, and shear (14). Prevention interventions are ordered and seem to be used more frequently for people with high-risk Braden Scale scores. However, data showing the effectiveness of the interventions themselves are lacking. Various expert groups, including the National Pressure Ulcer Advisory Panel (NPUAP) (15), the Agency for Health Care Policy and Research (AHCPR) Panel for Prevention and Prediction of Pressure Ulcers (2), and the American Medical Directors Association (AMDA) (3) recommend performing risk assessment in persons who cannot reposition themselves or have limited ability to do so.Quality Indicator 3: Pressure Ulcer PreventionNutritionIF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of ≥ 10% over 1 year or low albumin or prealbumin levels), THEN nutritional intervention or dietary consultation should be instituted BECAUSE poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development.Supporting Evidence. Studies have shown a relationship between risk factors for malnutrition, such as involuntary weight loss, anorexia, gastrointestinal illnesses, cancer, low caloric intake, and low albumin level and pressure ulcer formation; some studies have found a relationship between ulcer severity and severity of malnutrition (16–18). Furthermore, several studies have shown associations between low serum albumin level and the presence (19, 20), severity (17, 18), and healing (21, 22) of pressure ulcers. Other measures of nutritional status, such as body weight, have been shown to correlate with presence (19, 20) and severity (17) of pressure ulcers. Although no direct evidence shows that adequate nutrition will prevent ulcers, these studies provide indirect evidence that prevention of malnutrition will reduce risk for pressure ulcer formation.Quality Indicator 4Pressure Ulcer EvaluationIF a vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth and stage, size, and presence of necrotic tissue BECAUSE baseline assessment guides interventions, provides data for later comparison to evaluate healing, and can help predict time to healing.Supporting Evidence. No controlled trials of assessment of pressure ulcers have been done, and some experts believe that such studies may be impractical or irrelevant [23]. Several sets of guidelines support formal assessment of pressure ulcers, with documentation of findings, and focus on wound characteristics as a useful method for evaluating and documenting healing. The NPUAP suggested that 1) assessment should include multiple characteristics; 2) pressure ulcer staging is useful for diagnostic purposes only; and 3) size and stage are insufficient measures of healing and, although important, should be used in conjunction with assessment of other wound characteristics (24). Others have also acknowledged the role of assessment in planning and evaluating therapy (3, 25, 26).Observational data support these consensus statements and suggest that many wound characteristics are important predictors of healing or determinants of interventions.Wound Depth and StagePressure ulcers are commonly classified according to staging systems based on the depth of tissue destruction. Stage 1 lesions are least severe, and stage 4 are most severe. Staging systems are best used to diagnose wound severity and show a relationship to healing outcomes, but they do not facilitate monitoring of healing over time (2, 24, 26, 27). Full-thickness wounds (stage 3 and stage 4) generally take longer to heal than partial-thickness wounds (stage 2) (28). A prospective study showed that stage 2 pressure ulcers were 5.2 times more likely to heal than stage 4 pressure ulcers (29). Several other prospective studies also found that wound depth was a predictor of healing and time to healing (21, 30). Two retrospective studies demonstrated that wound depth was related to healing characteristics (31) and that change in depth was related to healing time (8), yet both studies found that initial wound depth did not correlate with healing.SizeSeveral studies have demonstrated a relationship between wound surface area and time to complete healing. In a prospective study to determine progress of healing within specific time frames, van Rijswijk (32) examined the characteristics of full-thickness pressure ulcers in 119 patients (48 of whom had full-thickness ulcers) who were seen in diverse settings. Healing was measured by using surface area tracings, with follow-up of 15 months. Mean reduction in wound surface area for ulcers that healed versus those that did not was significant at 2 weeks (45% vs. −3%) and at 4 weeks (77% vs. 18%). In a secondary analysis of full-thickness pressure ulcers, only 25% healed completely within 50 days, but three quarters had 50% reduction in surface area within 39 days (33). Ulcers with a surface area decrease of at least 39% after 2 weeks healed more quickly than those with a lesser decrease in surface area (median time to healing, 53 vs. 70 days). Retrospective studies also support the relationship between early reduction in surface area and shorter time to healing (8, 31).Presence of Necrotic TissueWound bed characteristics determine treatment options (8, 34). Several studies have shown that replacement of necrotic tissue with granulation and epithelial tissue is indicative of healing (32), and the presence of necrotic tissue at baseline is associated with slower healing (35).Other Characteristics and Assessment ToolsResults of studies of other wound characteristics, such as exudate and undermining, in relation to healing time have been inconclusive (8, 21, 33–36). Nonetheless, assessment is recommended because it can guide treatment (8).Use of a standardized instrument or tool for assessment and documentation of pressure ulcers, such as the Pressure Sore Status Tool (37) or the Pressure Ulcer Scale for Healing (36), is suggested, but no study has examined the effect of standardized evaluation and documentation on pressure ulcer outcomes.Quality Indicators 5 and 6Management of Full-Thickness Pressure UlcersIF a vulnerable elder presents with a clean full-thickness pressure ulcer and has no improvement after 4 weeks of treatment, THEN the appropriateness of the treatment plan and the presence of cellulitis or osteomyelitis should be assessed BECAUSE clean full-thickness pressure ulcers should show evidence of healing or improvement within 4 weeks and lack of improvement should stimulate a change in approach.Management of Partial-Thickness Pressure UlcersIF a vulnerable elder presents with a partial-thickness pressure ulcer and has no improvement after 2 weeks of treatment, THEN the appropriateness of the treatment plan should be assessed BECAUSE partial-thickness pressure ulcers should show evidence of healing or improvement within 2 weeks and lack of improvement should stimulate a change in approach.Supporting Evidence. No direct evidence indicates that reassessment of nonhealing ulcers will improve outcomes. However, it is logical that reassessment is a necessary first step to identify causes of and, hence, treat nonhealing ulcers.These two quality indicators are supported by evidence on rate of healing and healing outcomes from several studies. A randomized, controlled trial involving 85 patients found that up to 42% of stage 2 ulcers healed within 30 days and 75% healed within 60 days, whereas only 17% of stage 3 and 4 ulcers healed within 60 days (30). Similar outcomes were noted in a prospective cohort study of 89 nursing home residents with stage 2 or greater pressure ulcers. After 6 weeks of follow-up, 65% of stage 2 ulcers, 14% of stage 3 ulcers, and no stage 4 ulcers healed (29). In Brandeis and colleagues' (28) cohort study of 1626 patients with a stage 2 or greater pressure ulcer who were admitted to 1 of 51 nursing, up to 54% of stage 2 ulcers healed in 3 months and 74% healed in 6 months (28). Healing rates for stage 3 and 4 ulcers were slower; 31% and 23% healed in 3 months and 59% and 33% healed in 6 months, respectively. Data from a randomized, controlled trial (35) indicated much faster healing times for stage 2 ulcers and provide primary support for the 2-week time frame for the partial-thickness quality indicator: The median healing time was 9 to 11 days, and three quarters of the ulcers healed within 14 to 26 days, depending on topical treatment.In a retrospective study of 143 pressure ulcers, change in surface area at 1 week was a strong predictor of time to 50% healing. The median time to 50% healing among ulcers at all stages that had decreased surface area within 1 week was 21 to 26 days; in contrast, wounds with no change in surface area reached 50% healing in a median of 34 days (8), and an increase in surface area at 1 week was predictive of nonhealing.Reported mean or median times to healing are 8.7 to 38 days (22, 30, 35) for partial-thickness stage 2 ulcers; full-thickness stage 3 or 4 ulcers will heal after 8 to 10 weeks of therapy in 10% to 40% of patients (28, 32). Some investigators have shown that the percentage reduction in surface area after 1, 2, or 4 weeks of treatment is predictive of time to healing (8, 33). The basis for the 4-week timeframe in the full-thickness quality indicator is primarily supported by van Rijswijk and Polansky's study of full-thickness pressure ulcers and percentage reduction in surface area as predictors of time to healing (33).Quality Indicator 7Pressure Ulcer DebridementIF a vulnerable elder presents with a full-thickness sacral or trochanteric pressure ulcer covered with necrotic debris or eschar, THEN debridement by using sharp, mechanical, enzymatic, or autolytic procedures should be done within 3 days of diagnosis BECAUSE dead tissue is a physical obstacle to healing tissue and provides a medium for bacterial invasion and proliferation, which places the patient at high risk for wound infection.Supporting Evidence. Wound debridement can be performed by using sharp, mechanical, enzymatic, or autolytic methods. Sharp debridement involves use of a scalpel, scissors, or other sharp instrument to remove nonviable tissue. One multicenter trial of the effects of a topical growth factor versus placebo on wound healing in 118 patients noted incidentally that sharp debridement was positively associated with healing of diabetic ulcers (38). In this study, all patients received sharp debridement initially and then as needed throughout 20 weeks of follow up. In post hoc analysis, centers that used sharp debridement more frequently (debridement at up to 87% of visits) produced better healing rates (up to 83%) than did centers that used sharp debridement less often (debridement at 15% to 43% of visits; up to 64% healed). Sharp debridement can be safely performed in a fairly aggressive manner at the bedside in a sequential fashion (daily or every other day) by various health care providers. Attention to patient comfort is recommended (systemic or topical analgesia), and some have suggested benefits to combining bedside sequential sharp debridement with other forms of debridement to maximize response (39).Mechanical debridement involves the use of wet-to-dry dressings, whirlpool, or lavage or wound irrigation. The AHCPR panel recommended cautious use of mechanical wet-to-dry dressings for debridement because removal of dressing may cause trauma to new granulation and epithelial tissue. Because debridement with wet-to-dry dressings is painful, the AHCPR panel recommends pain management, such as administration of a systemic analgesic before dressing removal (25). Coarsely woven gauze or cotton sponges appear to be more effective than finer materials in mechanical debridement (40).Enzymatic debridement involves applying a concentrated, commercially prepared enzyme to the surface of the necrotic tissue, with the expectation that it will aggressively degrade necrosis by digesting devitalized tissue. A randomized, controlled trial of enzymatic debridement for necrotic wounds reported a mean time of 8 days to debride stage 4 pressure ulcers with an amorphous hydrogel dressing and a mean time of 12 days for debridement with an enzymatic preparation containing streptokinase and streptodornase (41). These times did not differ significantly, suggesting that an agent with enzyme activity was unnecessary.Autolytic debridement is use of the body's own mechanisms to remove nonviable tissue. Maintaining a moist wound environment allows collection of fluid at the wound site, which allows enzymes within the wound to digest necrotic tissue. Autolytic debridement, which typically involves adequate wound cleansing to wash out partially degraded nonviable tissue, is more effective than wet-to-dry gauze dressings because it removes only necrotic tissue and therefore protects healthy tissues (42–44). Mulder and colleagues (42) evaluated 16 patients in a randomized, controlled trial of a hypertonic hydrogel versus wet-to-dry gauze for wound debridement (the hypertonicity of the gel assists with autolytic debridement by pulling fluid into the area through osmotic forces) (42). The results suggested that the hydrogel could safely facilitate removal of dry adherent eschar from wounds. Other investigators also have found amorphous hydrogels to be effective in removing necrotic debris from wounds (43–45).Quality Indicator 8Pressure Ulcer Management: CleansingIF a vulnerable elder has a stage 2 or greater pressure ulcer, THEN a topical antiseptic should not be used on the wound BECAUSE topical antiseptics may harm the healthy wound bed.Supporting Evidence. No controlled trials have examined the effectiveness or safety of wound cleansing. Contraindications to the use of antiseptic and antimicrobial solutions for cleansing clean pressure ulcers are based on several laboratory studies (46–49). Two studies tested antimicrobial wound cleansers and solutions for toxicity to polymorphonuclear leukocytes. Results showed that even serial dilutions of the products diminished the viability and function of polymorphonuclear leukocytes; in contrast, nonantimicrobial solutions did not cause substantial toxicity to polymorphonuclear leukocytes (46, 47). On the basis of early animal model studies (48, 49), the AHCPR guidelines recommend normal saline as the preferred cleanser because it is noncytotoxic (25).Quality Indicators 9 and 10Pressure Ulcer Debridement for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN the ulcer should be debrided of necrotic tissue within 12 hours BECAUSE debridement will reduce dead tissue that provides a medium for bacterial invasion and may lead to systemic infection.Pressure Ulcer Culture for Systemic InfectionIF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN a tissue biopsy or needle aspiration sample should be obtained and sent for culture and sensitivity testing within 12 hours BECAUSE high bacterial burdens inhibit wound healing and may lead to systemic infection, and needle aspiration or tissue biopsy is the best indicator of bacterial invasion into tissue.Supporting Evidence. Wound infection extends the inflammatory phase of healing, delays collagen synthesis, retards epithelialization, and causes more injury to the tissues because the bacteria produce toxic by-products and compete with fibroblasts and other cells for limited amounts of oxygen and nutrients (50, 51).Signs and symptoms of systemic infection may be due to spread from a full-thickness pressure ulcer. To treat the infection, the source of the infection must be identified; impediments to healing must be removed; and, if possible, the organism causing the infection must be identified. Standard swab cultures do not aid in diagnosis of infection in pressure ulcers because they detect only surface contaminants and not the organism that caused the tissue infection (52). The AHCPR pressure ulcer treatment guidelines recommend wound culture of a tissue biopsy or needle aspiration sample when infection is suspected (25). This procedure may be impractical at some centers, and the NPUAP supports use of a specialized swab technique to culture pressure ulcer wound beds (24, 53). The recommended method of quantitative swab culture involves cleansing the wound with solution that contains no antiseptic. The end of a sterile cotton-tipped applicator is rotated in a 1-cm2 area of the wound for 5 seconds (53, 54) with enough pressure to cause tissue fluid to be absorbed in the cotton tip of the swab. The swab tip is inserted in the tube containing transport media and is sent to the laboratory. Swab culture was not included in the indicator because of the difficulty in distinguishing technique from the medical record.Tissue biopsy is removal of a piece of tissue by using a scalpel or a punch biopsy instrument. The area may be treated with topical anesthetic or injected with local anesthetic. The biopsy is pressure is to the area to and the tissue is sent to the laboratory. aspiration involves of a needle to a with of in the through to the is by the to the The needle is and at for two to The is to the the needle is and and the is sent to the the of systemic infection, the full-thickness ulcer should be treated to decrease the that it is a source of bacterial This is particularly for wounds with that are generally or with necrotic For such ulcers, healing time is because tissue may be Debridement of the with to of or removes dead tissue that provides a medium for bacterial growth and Because systemic infection is debridement of the wound bed should be done within 12 Indicator a vulnerable elder presents with a clean full-thickness or a partial-thickness pressure ulcer, THEN a moist environment should be with topical dressings BECAUSE wounds heal better in a moist Evidence. Several investigators have a moist environment with dry dressings for wound healing. have noted faster healing with moist wound dressings than with wet-to-dry saline gauze dressings (22, The AHCPR guidelines on pressure ulcer treatment which are supported by the American Medical Directors Association (3) and NPUAP also the use of moist dressings over dry an increase in pressure ulcer the of the AHCPR guidelines on pressure ulcers, quality indicators are supported by substantial a literature and with a expert panel 11 valid quality indicators for pressure ulcers were identified. These indicators pressure ulcer care from prevention and assessment to topical Although they are not they provide a baseline for measures that may between quality and Pressure Pressure Ulcers in Prediction and of Health and Health Agency for Health Care Policy and AHCPR Pressure American Medical Directors A study of pressure ulcer prevalence and in care Wound National prevalence pressure ulcer a on Wound The for Quality Wound for 30 October Healthy People of Health and Assessing care of vulnerable methods for developing quality A quantitative analysis of wound characteristics as early predictors of healing in Los University of California, Los Pressure and Wound A for and Braden Bergstrom validity of the Braden Scale for pressure risk in a nursing home Bergstrom Braden pressure ulcer a multisite study of the predictive validity of the Braden Bergstrom Braden study of of pressure ulcers and the relationship between risk characteristics, and prescription of preventive Bergstrom Braden A prospective study of pressure risk among A comparison of patient risk for pressure ulcer development with nursing use of preventive on Pressure Ulcer National Pressure Ulcer Advisory at The role of nutrition in prevention and healing of pressure ulcers. in the of pressure and nutritional Pressure among hospitalized factors for pressure A comparison of and beds or therapy for pressure A pressure healing with van Rijswijk Braden Pressure ulcer patient and wound an AHCPR Wound of National Pressure Ulcer Advisory Wound

Use of the DermaBlade for Debridement of Hypergranulatory Wound Tissue.

Freedom of Choice: Updated Dining Practice Standards Call for Diet Liberalization

BACKGROUND Chronic nonhealing wounds are a major complication for many veterans. Particularly at risk are veterans with reduced mobility, such as those who have suffered a spinal cord injury (SCI). Chronic wounds cause significant suffering, including profound negative effects on general physical health, socialization, financial status, body image, level of independence, and control. For individuals with SCI, the development of a pressure ulcer is one of the leading causes of readmission to the hospital after acute rehabilitation and a major source of morbidity and even mortality. The management of chronic wounds is also extremely costly for clinical facilities, from the acute care setting to long-term care. Many clinical practice guidelines (CPGs) for wound care are currently being issued with the overall goal of reducing the incidence and prevalence of this significant healthcare complication. CPGs have the potential to improve the standard of care for chronic wounds and decrease associated costs. A wealth of basic science and early clinical trials are being carried out in the field of chronic wound care research. However, there remains a disconnect between early stage research efforts and implementation as routine clinical practice in the care of veterans with chronic wounds. The 2nd International Conference on Evidence Based Practice in Wound Care: The Effective Implementation of Pressure Ulcer Clinical Practice Guidelines was held in Cleveland, Ohio, in June 2009 [1]. This program was designed for the many specialties involved in the interdisciplinary field of wound care research. The focus of the conference was on topics related to the effective selection and implementation of evidence-based CPGs. Over 150 attendees were provided with educational tools to enable them to effectively implement evidence-based practice approaches to pressure ulcer care. While many felt that they were familiar with CPGs for their specialty, there were concerns that implementation could be hindered by lack of support and continuing education in best evidence-based practices for wound care. In conjunction with the 2nd International Conference on Evidence Based Practice in Wound Care, an expert panel was convened in June 2009 to develop a research agenda based on critical knowledge gaps regarding pressure ulcers in individuals with SCI and on the implementation of advanced clinical practices. A literature-based discussion of the consensus panel conclusions is presented as a second Guest Editorial in this issue of JRRD [2]. The research articles presented illustrate both preclinical and clinical research that will lead to improved rehabilitative and lifetime outcomes for at-risk veterans, particularly those with SCI. Kath M. Bogie, DPhil ARTICLES IN THIS ISSUE Effect of sensory and motor electrical stimulation in vascular endothelial growth factor expression of muscle and skin in full thickness wound. Asadi et al. Electrotherapy for the treatment of chronic wounds has long been known, and there have been many clinical reports conducted on the technique. However, widespread implementation has been limited by lack of definitive proof demonstrating the positive effects of electrical stimulation (ES) on wound healing. The current limitations imposed on electrotherapy usage by the Centers for Medicare and Medicaid Services and the lack of Food and Drug Administration approval reflect the underlying deficit in understanding of the physiological mechanism that is an essential precursor to optimization of clinical therapy. In their article, Effect of sensory and motor electrical stimulation in vascular endothelial growth factor expression of muscle and skin in full thickness wound, Asadi et al. report on a preclinical study employing an acute animal wound model [3]. Varying ES paradigms were employed to study the effect on angiogenesis, as indicated by expression of vascular endothelial growth factor (VEGF). …