In This Issue of JWOCN
This issue of the Journal addressed multiple timely topics, from the significance of our heritage to cutting edge research, documenting our contribution to care in the 21st century. Because my editorial message is designed to provide an overview of how articles published in the current issue of the Journal contribute to the evidence base for our practice, it is unusual for me to include the President's Message. However, this issue is an exception. This issue's President's Message not only provides a summary of one the administrative decisions undertaken by the WOCN Board but also provides a substantive reminder of the significance of our history, and the urgent need to archive and study this history before it is forever lost. Read Jan Colwell's message for its masterful review of landmark research by pioneer ET/WOC nurse leader Edith Lenneberg and her colleague John Rowbotham. You may be surprised to realize how close many of the issues faced by clinicians in 1970 are to the ones we face in 2008. More importantly, I personally ask you to pay special attention to Jan's call for archival materials. Our specialty practice was born in the late 1950s and many of our pioneers (including Lenneberg) are no longer with us. As Jan's message vividly illustrates, preservation of this material is more than a matter of interest; it is an irreplaceable record of the victories, struggles, and unresolved challenges that form our heritage and continue to challenge clinicians in the early 21st century. Fortunately, a growing number of nurses at the doctoral level are studying to be historians, and several prestigious university-based schools of nursing have established historical centers that preserve our history and train the nurses who help us preserve and learn from our heritage. I personally urge you to contribute to this effort by identifying and contributing archival materials for the society's collection. These materials include copies of the journal, programs from prior meetings, published and unpublished research, newsletters, and correspondence from mentors or colleagues. Are you a past officer of the North American Association of Enterostomal Therapists, International Association of Enterostomal Therapists, or WOCN? Are you an archivist for one of the WOCN regions or affiliates? Do you know of records kept by someone you consider a pioneer of enterostomal therapy or wound, ostomy, and continence nursing? If so, please watch for upcoming announcements and donate materials to the WOCN archive.
"How do I justify my position?" This legitimate question may be the most common asked of our journal or Center for Clinical Investigation. It appears that the Canadian Association of Enterostomal Therapists (CAET) has grappled with this same question and I am pleased to announce publication of a study sponsored by the CAET focusing on a model for care that not only demonstrates faster wound-healing times but also reveals the cost-effective care delivered when an ET/WOC nurse manages chronic or acute wounds in a community setting. Connie Harris and Ronald Shannon report on an innovative study that, I believe, may serve as a model for demonstrating the value of the WOC nurse in the management of ostomies, continence, and wounds, in Canada and other countries including the United States. The value of this article is further enhanced by commentary from CAET President Kathy Kozell, who provides a succinct overview of the Canadian healthcare system, and the contribution of ET nurses to the health of all Canadians.
Deanna Vargo provides an excellent overview of how wound care clinicians in the United States obtain reimbursement for their services. Read her article for a timely review of ICD-9 and CPT codes, and up-to-date Web-based recourses for accessing CMS policies regarding reimbursement for the various clinical services provided by outpatient or hospital wound care services or clinics.
Morris Magnan and JoAnn Maklebust report on the effect of Web-based training designed to teach nurses to accurately use the Braden Scale for Predicting Pressure Sore Risk in daily practice. This article is especially timely as WOC nurses based on acute care settings prepare their staff to comply with pay-for-performance policies from CMS. Have you ever wondered what the nurses who developed and validated the scale might have to say if asked to comment on the latest research using their instrument? Fortunately, this article is enhanced by commentary from not one, but both of the principle researchers who brought this now classic instrument for pressure ulcer risk assessment-Barbara Braden and Nancy Bergstrom. Is there any better way to place a research report into the current evidence base of our practice than to hear from the researchers and the originators of the instrument?
Our continence section opens with an article by A. Wagg, D. Lowe, P. Peel, and J. Potter that examines continence services in England, Wales, and Northern Ireland. Based on a national audit, it examines the fulfillment of a UK Department of Health initiative to provide integrated continence services for elders. Launched in 2000, the researchers found significant gaps in services in acute, long-term, and community-based settings. While this comprehensive project focused on continence services in the United Kingdom, the results are almost certainly applicable to the United States and to others as well.
CCI Director Donna Bliss and JWOCN Statistical Consultant Kay Savik report on use of an absorbent dressing for persons with fecal incontinence. This article provides an excellent example of how a novel clinical observation, in this case questions about why patients continued to use an absorbent dressing far longer than would be expected following anorectal surgery, can be turned into a simple and elegant study that provides valuable knowledge about the clinical application of the dressing in the patient with fecal incontinence. Read this article to gain insight about the challenges and choices made by patients seeking to effectively contain low-volume (usually liquid) stool, and the use of an absorbent dressing for containing fecal material and protecting both the perianal skin and clothing.
In addition to Jan Colwell's President's Message, 2 of the journal's regular features address ostomy care. In this issue's Challenges in Practice feature, Vicki Haugen describes surgical modification of her Hartmann's Pouch, creating a mucus fistula allowing antegrade irrigation of her distal bowel. Regular irrigation provided long-term relief from chronic diversion colitis, without incurring the substantial added cost associated with ongoing short-chain fatty acid enemas. In this issue's Evidence-Based Report Card, Barbara Hocevar and I systematically review the literature to determine whether intestinal diversion (colostomy or ileostomy) improves functional, quality of life, or clinical outcomes in selected patients with severe bowel dysfunction associated with spinal cord injury.
When Disaster Strikes in Your Community: Are You Prepared?
This issue's View From Here was written by Bernie Cullen. Bernie's background justifies self-descriptive labels including certified wound-ostomy nurse, WOCN Society past-president, vice president of acute and post-acute care services, chair of the Clinical Practice Council of the East Jefferson General Hospital, journal author, and many others. However, for this contribution, Bernie simply describes herself as survivor. I flatter myself as a survivor of the mild chaos and occasional distress that clutters all of our lives, but I cannot begin to imagine what this term really means. Bernie, as well as every professional colleague, and every resident of New Orleans, as well as many other communities in the Gulf Coast region of the United States, are all too aware what this term really means. They also know the real meaning of a few other terms like disaster, catastrophic, and the ever-present aftermath of this type of cataclysmic event-patience. Read Bernie's View From Here to gain a first-hand understanding of what these words truly mean, and what we can do to not only support our colleagues in New Orleans but also what we must do to truly prepare for the very real possibility that a similar disaster could strike in our community and our healthcare facility.
Evidence From Other Publications
Wound Care
Adherence to care recommendations is on ongoing challenge when managing an ostomy, urinary or fecal incontinence, or a chronic wound. In a recent issue of Archives of Dermatology, Heinen and coinvestigators1 interviewed 150 patients seen in 12 outpatient wound care centers in Holland. They found that only 39% adhered to compression, an essential component in the care of venous insufficiency ulcers, and 35% adhered to recommendations related to physical activity. While this study did not test the efficacy of any intervention designed to increase adherence, it eloquently illustrates the large gap between the care measures we prescribe and the percentage of patients who adhere to these recommendations.
Prevention is central to wound care, whether it is the eradication of unavoidable pressure ulcers in the hospital or nursing home or primary prevention of venous ulcers. Margolis and associates2 reviewed selected data from the general practice database, which contains information on 414,887 community-dwelling persons in the United Kingdom managed by general practice physicians. They measured the incidence of venous ulcers in 62,886 patients exposed to b-adrenergic agonists and 54,861 patients exposed to b-adrenergic antagonists. The incidence of venous ulceration in patients treated with a b-adrenergic agonist was 15.5% as compared with 18.4% in those not managed with this drug class. The incidence of venous ulceration in patients treated with a b-adrenergic antagonist was 18.2% as compared with 19.9% in those not managed with this drug class. Adjusted odds ratios for patients exposed to a b-adrenergic antagonist was 1.02 (95% confidence interval [CI], 0.98-1.11), indicating no protective action associated with b-adrenergic antagonist therapy, although pharmacotherapy was not shown to increase the risk of venous ulceration either. In contrast, treatment of patients with a b-adrenergic agonist yielded an adjusted odds ratio of 0.44 (95% CI, 0.42-0.45), indicating a statistically significant and clinically relevant protective (preventive) effect when patients were treated with this drug class. It is important to note that these drugs were not prescribed for prevention of venous leg ulcers; they were prescribed for pulmonary conditions such as asthma or hypertension consistent with recommended indications. Further, these retrospective data do not allow us to definitively conclude that b-adrenergic agonists are effective for the prevention of venous ulcers. Nevertheless, the results are strongly suggestive and provide a powerful argument that a randomized clinical trial to determine whether administration of a b-adrenergic agonist might prevent venous ulcerations in high-risk persons, or recurrence in patients with a history of venous leg ulcers, is indicated. These results also provide a basis for selecting a b-adrenergic agonist when treating patients with hypertension, congestive heart failure, or other conditions who are also considered at risk for venous ulceration.
Ostomy Care
Despite the rise in the frequency and popularity of orthotopic neobladder construction, the ileal conduit continues to act as a viable alternative for many patients undergoing radical cystectomy for bladder cancer. In a recent edition of the Journal of Urology, Kouba and colleagues3 reviewed the records of 137 patients who underwent creation of an ileal conduit in order to identify the incidence of stomal complications and associated factors. Twenty patients experienced 21 stomal complications, including parastomal herniation (seen in 13.9%), stomal stenosis (seen in 1 patient), and prolapse (seen in 1 patient). Patients who experienced stomal complications were then compared with those who remained free of complications. Only 1 potential risk factor for stomal complications emerged-obesity. When patients were stratified based on BMI, obese persons experienced a complication rate of 27.3% as compared to 16.4% in those patients classified as overweight or 4.1% among patients who were not overweight. This finding is important to WOC nursing practice since obesity is a modifiable risk factor, and knowledge of its association with parastomal herniation risk can be incorporated in preoperative counseling and postoperative management.
Continence Care
Does a hysterectomy increase the risk for developing urinary incontinence? This hotly debated question is frequently asked by both women and continence nurses who provide care for these women. Altman and coinvestigators4 reported on a population-based case-control study of 165,269 Swedish women who underwent hysterectomy between 1975 and 2003. This large group of women was compared with 479 506 women who did not undergo hysterectomy. Cases (those who underwent hysterectomy) were matched based on age and residence. Based on a 30-year observational period, stress urinary incontinence rates among women who underwent hysterectomy was 179 (95% CI, 173-186) per 100,000 person years versus 76 (95% CI, 73-79) per 100,000 person years among women who did not undergo hysterectomy. An increased risk for stress urinary incontinence persisted irrespective of surgical technique (abdominal vs vaginal). Time since surgery slightly influenced the risk, the peak occurrence was found within 5 years following surgery. While this study does not definitively answer all of the clinically relevant questions associated with hysterectomy and stress urinary incontinence risk, it does provide additional evidence that women should be counseled about this potential risk prior to hysterectomy as well as evidence that women undergoing hysterectomy should be taught to perform pelvic floor muscle exercises in order to diminish this risk.
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