Traditionally, the editorial has provided a forum for the editor (or a member of the editorial board) to write an opinion about an issue facing WOC practice, nursing practice, or healthcare in its broadest perspective. Like most editors, I have written many such editorials. With experience, they are comparatively simple to write, require few references, and are based on the very thing that we increasingly demand that other authors minimize: expert opinion in the absence of a research or clinical evidence base. As a reader and a member of the editorial board, I continue to demand this of authors, and I believe that you should demand the same standard of me. Beginning with this issue, I will substitute a new feature, "Context for WOC Practice," for the traditional opinion-driven editorial. I will begin with brief comments about articles appearing in this issue of the Journal of Wound, Ostomy, and Continence Nursing, followed by alerts about at least 3 articles recently published in other journals that affect our practice. Observations on WOC practice or the WOCN will still appear in guest editorials.
As always, I encourage you to express your opinion about the value or need for the new "Context for WOC Practice" feature, or any aspect of the journal through a letter to the editor. All are carefully read, and most are published for others to read and consider.
In This Issue of JWOCN
Pressure ulcer staging system. Although it continues to be widely used in the clinical setting, increasing research and clinical opinion have converged to point out significant limitations to the current staging system. Specific limitations include the inability to identify or differentiate the underlying pathophysiology of wounds, etiologic issues related to Stage 2 (partial-thickness) lesions, and how to classify deep tissue injuries. As a result of this growing concern, the National Pressure Ulcer Advisory Panel (NPUAP) convened a consensus forum to examine the existing staging system and issues surrounding deep tissue injury. Doughty and a group of colleagues (whose names comprise a partial "who's who" of wound care experts in the WOCN) have summarized the white papers provide by the WOCN and other stakeholders interested in wound care, the WOCN Society's response to the consensus conference, and the consensus forum discussion. Read this article for a comprehensive summary of the current staging system, its limitations, and suggestions for possible revisions. In addition, I wish to draw your attention to comments near the end of the article, when the authors observe that the NPUAP consensus forum served as a beginning of a reexamination of the existing staging system. Changes seem inevitable, but any viable system emerging from this process must be based on clinical research and clearly demonstrate its ability to adequately describe a wound, assess severity and etiology, and provide a framework for management. Doughty and colleagues have provided a lucid and comprehensive synthesis of the first steps in a change process. It is up to the society and its Center for Clinical Investigation to provide the clinical evidence that leads to an updated and more clinically relevant staging system.
Extravasation injuries among neonates. A survey of 31 neonatal intensive care units caring for 742 neonates receiving IV fluid therapy found that extravasation injuries resulting in skin necrosis occur in approximately 38 cases per 1000.1 The majority of injuries involved peripheral cannulae, and total parenteral nutrition solutions were most commonly implicated, followed by sodium bicarbonate solutions and dextrose solutions mixed with antimicrobial medications, insulin, magnesium, and/or aminophylline. Although acknowledged as a "short report," these findings represent one of the largest studies of extravasation injuries in neonates completed to date and clearly highlight the massive gaps in our knowledge of the epidemiology, etiology, and pathophysiology of these often devastating wounds. In this issue of the journal, McCullen and Pieper reviewed charts of 25 neonates with extravasation to determine risk factors and to design effective prevention strategies. They were unable to identify any statistically significant risk factors. This outcome is not surprising given the small sample size, although they do report that their findings closely reflected existing published reports. Nevertheless, their research is clinically relevant and the report provides valuable reading. In addition to a comprehensive and succinct summary of the limited clinical evidence related to extravasation injuries among neonates, they report that only 36% of infants had adequate documentation of the size and location of the wound and subsequent management. Their finding extends the observations of Wilkins and Emmerson1 who noted that no consensus exists concerning the management of extravasation wounds in neonates and that specialist wound care nurses were involved in the management of only 17% of reported cases. Although it is possible to argue that prevention of IV fluid extravasation wounds among neonates is primarily the responsibility of neonatal nurses, the lack of clinical evidence concerning the assessment and evaluation of these wounds falls clearly within the scope of practice of WOC nursing. This reality is recognized not only by McCullen and Pieper, the Neonatal Nurse Practitioner, and well-known WOC nurse and professor who wrote this article but also by Wilkins and Emmerson,1 neonatologists practicing in a busy intensive care unit who clearly perceived wound care nurses as an essential component of the team needed to prevent and manage these injuries.
Long-term indwelling catheter management. A MEDLINE search using the key words "urinary tract" and "indwelling catheters" revealed 522 articles, but a more detailed search revealed that the majority of articles focus on short-term indwelling catheters, typically defined as those that remain in place for 14 days or less.2 The reasons for this disparity are easily identified: it is far easier and more economic to design and complete studies of individuals undergoing short-term catheterization, and companies that manufacture catheters are more likely to fund this type of research when seeking additional information about the performance of their products in the clinical setting. Nevertheless, WOC nurses often care for persons with long-term indwelling catheters and the multiple serious complications and challenges associated with their maintenance and management. Four articles in this issue of the journal deal with problems associated with managing indwelling catheters. Two focus on short-term catheters, one focuses on both short-term and long-term indwelling catheters, and one focuses on long-term catheters only.
Siegel completed a survey of nurses in a community-based acute care facility and found that although 98% reported that securing indwelling catheters is an essential aspect of catheter management, only 14% of catheters around the time the survey were stabilized. Fernandez and associates completed a systematic review examining the duration of short-term indwelling catheters the timing of their removal. Although clinical evidence remains sparse, they found that management of short-term indwelling catheters requires a balance between avoidance of voiding dysfunction associated with early removal and risk of urinary tract infection associated with delayed removal. Removal within 24-48 hours was no more likely to result in urinary retention and the need for recatheterization. In addition, removal after 48 hours was associated with an increased risk of urinary tract infection and prolonged hospital stay. Webster and coworkers add to the evidence base surrounding this clinically relevant topic through a randomized controlled trial comparing the effect of midnight catheter removal to morning removal in a group of 210 medical-surgical patients with short-term indwelling catheters. Unlike previous studies involving patients undergoing urologic surgery,3-5 no differences in length of hospital stay, mean volume of first void, or the need for recatheterization were found. The results of this well-designed study are important because they expand our knowledge of the effect of timing of short-time catheter removal while warning of the pitfalls inherent in applying findings from studies completed in one group (urologic surgical patients) to a different population (general medical-surgical patients).
Wilde and Dougherty completed a descriptive study of self-monitoring behaviors among 30 patients with long-term indwelling catheters. They found that patients with long-term catheters are acutely aware of the need to self monitor their catheters for blockage resulting from sediment or kinking, and that they associate urinary tract infection risk with difficult or "rough" catheter insertion episodes and catheter blockage. Not surprisingly, study participants shared multiple insights into catheter management and strategies for preventing urinary tract infections. The authors call for translation of this experience into a management plan for the patient with a new indwelling catheter, as well as further research into the relationship between self-management behaviors and infection risk. Additional research is urgently needed in both of these areas, as are qualitative studies examining the experiences of persons with long-term indwelling catheters.
The ongoing search for the optimal technique for delivering negative pressure wound therapy has sparked debate reflected in this issue of the journal and on our Web forums. In the Clinical Challenges feature, Campbell presents 3 cases where the Versatile 1 Wound Vacuum System (Blue Sky Medical, Carlsbad, Calif) was successfully used as part of a comprehensive and complex wound management strategy. She provides a rationale for choosing a specific product to deliver negative pressure wound therapy, partially based on research originally published in the Russian literature and more recently translated into English. A previous Evidence-Based Report Card published in the Journal of Wound, Ostomy, and Continence Nursing outlined clinical evidence supporting the use of Vacuum Associated Closure Therapy (KCI, San Antonio, Tex).6 Although the debate is important, definitive answers await further research, including carefully controlled head-to-head trials comparing the 2 available systems. In the interim, I recommend reading both Campbell's cogent case series and Bonham's thoughtful commentary that places negative wound pressure therapy in the larger context of the complex management strategies needed to heal the severe and complicated wounds that typify WOC practice.
Evidence From Other Publications
Wound care. In the August 2005 issue of the American Journal of Nursing,7 Duimel-Peeters summarized existing evidence about the use of massage for preventing pressure ulcers. Based on this review of extremely sparse evidence, the author concludes that evidence is mixed and that massage is contraindicated in inflamed or unhealthy (injured) tissue. When massage is undertaken, the clinician should use a slow rhythmic hand movement that is molded to the shape of the skin and avoids kneading, tapping, shaking, or vigorous rubbing. Given the subtleties of the massage techniques recommended by the author, the difficulty judging tissue health in high-risk patients, and the paucity of supporting evidence, it seems dubious to recommend massage as a routine strategy for pressure ulcer prevention. Nevertheless, I strongly recommend reading this brief report and formulating your own judgment. Although massage may seem an unlikely prevention strategy to the wound care specialist, it retains some attraction for the generalist that may be piqued by this article and applied to patients with inflamed or injured skin.
Ostomy care The cause of pouchitis after creation of an ileoanal pouch anastomosis remains unknown, and effective prevention strategies have not yet been formulated. In the October 2005 issue of the American Journal of Gastroenterology, Yamamoto and coworkers8 performed sequential mucosal biopsies on patients undergoing restorative proctocolectomy at the time of ileostomy closure and 3, 6, and 12 months after closure. Although cytokine levels in the anal pouch were comparable to those found in the proximal ileum at the time of ileostomy closure, they were elevated at 3 months and remained elevated at 6 and 12 months. Elevation of these cytokines indicates inflammation of the pouch, and the timing of the change indicates that the presence and retention of fecal materials in the pouch as the culprit. Though these findings alone do not allow us to conclude that fecal stasis in the newly created pouch causes pouchitis, they do raise the argument that this immunologic response to reconstruction of the gastrointestinal system increases the risk, particularly when combined with bacterial colonization or overgrowth.
Continence care. In the January 2006 issue of the Journal of Urology, Burgio (a research psychologist) and associates9 (including nurse researchers) reported results of a randomized clinical trial involving 125 men undergoing radical prostatectomy for localized prostate cancer. Men who underwent a single session of preoperative pelvic floor muscle training recovered continence faster than those who underwent "standard care" (written instructions). This exciting randomized clinical trial has multiple implications for WOC practice. They include the efficacy of clinician directed pelvic floor muscle training as compared to "written instructions," the efficacy of preoperative training on continence restoration after radical prostatectomy, and the efficacy of a single preoperative training session as a routine intervention. Pelvic floor muscle training is a critical component of continence management that should be incorporated into routine WOC practice. This well-designed randomized clinical trial provides yet another clinical application for this effective nursing intervention.
References