nursing research

Issue: Volume 65 - Issue 5 - May 2019 ISSN 2640-5245

Top-Scoring Nurse Research Abstracts Symposium on Advanced Wound Care (SAWC) Spring 2019

Alice Bourke, MN; Natalie Scott, MN

Our district nursing service faces a burgeoning aging population with increasing numbers of complex venous leg ulcer (VLU) referrals. Our response to this growing wound problem has been to implement a new specialized, early assessment and intervention model. Previous service audits identified recurrent VLUs take longer to heal than first presentations. Previous VLU healing times averaged 33 weeks.

A clinical audit research project was undertaken (2017-2018) that aimed to determine healing rates and establish whether early intervention and compression bandaging in the first 6 weeks of ulceration could reduce chronicity. A secondary aim was to identify healing rates for new VLUs over recurring VLUs.

The clinical, etiology, anatomy, pathophysiology (CEAP) venous classification tool was used to enable early identification of potential slow healing. Doppler ankle-brachial pressure indices (ABPIs) were measured and compression bandaging commenced accordingly. Healing expectations were set at 25%cm2 wound area reduction within the first 4 weeks. This was monitored using accurate reliable camera imaging devices with confidential patient records system capability

A retrospective observational study was implemented. Lower limb ulcerations were identified by statistical coding (excluding arterial and cancerous wounds). Time to heal and time until the patient received a Doppler assessment were analyzed using descriptive statistics and their relationship using nonparametric Spearman’s rho test. Continuous variables analysis was measured by means of variance (ANOVA) and independent Students t test. A statistical software package provided statistical analysis.

Out of 247 VLUs, 219 (88%) healed within 28 weeks with an average healing time of 9.70 ± 7.12 weeks, 82% healed by 24 weeks, 49% received compression in first 6 weeks,

68.4% received compression during their 24+ weeks VLU duration. “Other” ethnicities showed significant statistical difference in age of VLU onset.

Investing in increased access to specialized wound nurses enabled improved VLU healing outcomes and reduced chronicity.

How Effective Is Your Wound Cleanser? An Evaluation Using Bacterial Fluorescence Imaging

Rosemary Hill, BSN CWOCN WOCC(C)

Introduction: Wound cleansing to remove surface bacteria is an essential component of wound bed preparation. Because most cleansers are cytotoxic, our provincial authority mandates that only normal saline can be used. The province recently conducted an evaluation across 6 sites of 2 novel, noncytotoxic, tissue-compatible wound cleansers: a hypochlorous acid solution, and a modified sodium hypochlorite solution (NaOCl). Our site was uniquely able to assess relative product effectiveness due to our real-time bacterial fluorescence imaging device.

Methods: Wounds (N = 9) were cleansed with normal saline, as per standard practice, after which a fluorescence image was acquired to visualize any concerning levels of bacteria remaining within and around the wound. Wounds then were soaked with hypochlorous acid for at least 6 to 10 minutes (per manufacturer guidelines), cleansed, and re-imaged. Lastly, wounds were sprayed with a modified sodium hypochlorite solution and immediately cleansed and re-imaged.

Results: Pseudomonas aeruginosa, which fluoresces cyan, was rampant in this patient series. Fluorescence images demonstrated that: 1) Pseudomonas and other bacteria often extend into periwound tissues, 2) saline cleansing left behind widespread bioburden in all wounds, and 3) sodium hypochlorite solution was superior to hypochlorous acid in removing Pseudomonas and other bacteria. In all wounds that were cultured (5/8), microbiology confirmed bacterial presence at moderate/heavy loads. Patients reported no product-related irritation or pain.

Conclusions: Our evaluation found that a modified sodium hypochlorite is superior to normal saline in cleansing a wound, and just as fast. Based on these results, we recommend that wounds exhibiting heavy bioburden be cleaned with modified sodium hypochlorite solution. These wounds can be identified from bacterial fluorescence images, without which this real-time evaluation of cleansing effectiveness would not have been possible and regions of concern could not have been specifically targeted.

A Digital Point-of-care Solution to Improve Patient Experience and Adherence: Instant Personalized Product Handouts

Elaine Song, MD; and Catherine Milne, APRN, MSN, CWOCN-AP

Background: To adhere to care plans, patients need to know which products to purchase, where to obtain them, how much they cost, and how to use them. However, clinicians’/caregivers’ busy schedules and lack of easily available information are frequent obstacles to meeting these needs satisfactorily. We aimed to develop a solution to quickly generate customized product handouts with this information for patients.

Method: Using the Design Thinking methodology, the solution was developed as a module within a clinical/reimbursement decision support web application for wound care and hyperbaric clinicians, as follows: Clinician needs/desired features were identified through interviews;

Module was developed with robust programming language, library, framework, and application programming interfaces (APIs);

Patients/clinicians of 4 wound clinics completed 2 rounds of evaluation, and feedback was incorporated into the final version.

Results: The final module instantly generates patient-centric, customized product handouts on more than 1000 different wound care products.

To generate a handout, the clinician chooses a product, enters the patient’s ZIP code, and selects desired type of information. The handout is automatically populated with selected information, which may include: product description, durable medical equipment (DME) suppliers (local, online and/or recommended by clinician), custom notes, pricing, and Medicare coverage/copayment information. Clinicians can bookmark, print, and/or email handouts to patients/caregivers.

Upon initial evaluation, 100% of the surveyed clinicians indicated they would use the module daily/weekly; 80% indicated it meets their needs “very well” (versus “moderately”/“not as much”).

Handouts were incorporated into the clinical workflow, and a second evaluation conducted: From the patients’ perspective, handouts were “helpful”/“very helpful” (average score: 4.2/5, 1:“not helpful”, 5:“very helpful”). Clinicians found that 87.5% of handouts shared with patients were “useful”/“very useful” in increasing adherence to the care plan.

Conclusion: A digital point-of-care solution that generates customized product handouts with clinical, coverage, pricing, and supplier information was developed. This tool may significantly improve patient experience/adherence while saving clinician time.

Nurse Knowledge and Confidence in Nutrition for Wound Healing

Sheree Stachura, JD, BSN, WCC, RN-BC; and Catherine Abounader, BA, RN

Acute and chronic wounds occur in patients regardless of age and demographics. Nutritional interventions have been shown to increase wound healing rates; however, patients often lack this knowledge and rely on health care providers to counsel and guide them. The literature shows that nurses do not have the confidence to provide this needed education because of their own knowledge deficit. The purpose of this project was to examine the impact of education regarding nutrition for wound healing on nurse knowledge and confidence with providing patient education. 

A sample of nurses from 2 hospitals (a critical access hospital and an orthopedic unit in large hospital) were invited to complete a presurvey (n = 20), participate in an educational intervention, and complete a post-survey (n = 16). Before receiving the educational intervention, the nurses agreed or strongly agreed (M = .95) that it is important to provide nutritional education to their patients. The nurses did not have the knowledge base to provide education to their patients, and they did not feel confident in their ability to use the teach-back method to provide that education. After the completion of an educational intervention that featured a brief presentation and brochure that contained recommendations for wound healing, nurses increased their knowledge of basic nutritional principles (P = .0009, g = 1.268), they felt more confident in their ability to provide nutritional education to their patients (P = .001, g = 1.3), and felt more confident in their ability to use teach-back to provide nutritional education to their patients (P = .068, g = .652). This project demonstrates that a brief presentation and a simple brochure featuring nutritional information for wound healing increased the bedside nurses’ knowledge and confidence in providing education and guidance to a patient with a healing wound.

Harnessing the Microbiome to Rapidly Resolve Peristomal Skin Complications

Diana Gallagher, MS, RN, CWOCN, CFCN; and Jennifer Juergens, BSN, RN, CWOCN, CFCN

Almost all ostomates experience peristomal complications at some time. In one study thought to grossly underreport complication rates, incidence ranged from 18% to 55%. Factors that predispose patients to complications include poorly sited and poorly constructed stomas, obesity, wound complications, and disease. Common peristomal complications include dermatitis, candidiasis, folliculitis, trauma, contact dermatitis and pseudoverrucous lesions. These alterations in skin integrity cause pain and pruritus and interfere with successful pouching. Pouch failures result in embarrassing leaks and worsening of these skin conditions with further exposure to stool, urine, and trauma with frequent pouch changes.

Traditional management involves a variety of treatments to the skin, including powders and sealants, correct use of pouches and accessories, and advanced treatments. All treatments are aimed at correcting the problem, but little attention is paid to improving and strengthening the skin’s outermost layer, the stratum corneum. Skin plays an important role in ostomy care, providing the surface on which the pouching system is adhered. Intact, dry epidermis and a well-fitted pouching system enable a sustained, predictable wear time. Because skin is critical to pouching success, strong, healthy skin should be a primary goal.

Expanding research on incontinence-associated dermatitis (IAD) and wound care, a novel, low-pH microbiome optimizing treatment was used on peristomal skin along with standard pouching. Prior research showed this intervention enhanced skin’s adhesion, cohesion, and integrity by downregulating a group of enzymes that leads to shedding of the stratum corneum. This study with >20 patients resulted in rapid resolution or significant improvement of peristomal complications (within 24 to 72 hours) with a simple application before pouching, a marked improvement over standard care. Additional research is needed to further explore how optimizing the stratum corneum can impact practice in all areas of wound, ostomy, and continence.

Wound Exudate and Super-Absorbent Dressings with High Fluid Retention Capacity: The Disconnect Between Clinical Perception and Documentation

Catherine Milne, MSN, APRN, CWOCN-AP

Background: Superabsorbent dressings (S-ADs) are used for moderate to high exudating wounds, although fluid retention capacity may differ among manufacturers due to dressing design and construction. Because of their ability to retain exudate without periwound maceration, S-ADs reduce dressing change frequency. In vitro studies demonstrate S-ADs can reduce inflammatory matrix metalloproteases and bioburden. Despite this, dressing availability often is governed by regulatory requirements based on the amount of exudate. Under the current Medicare Surgical Dressing Benefit, S-ADs can be obtained daily, assuming documentation in the medical record reflects moderate to large amounts of drainage. Unfortunately, exudate amounts often are based on the perception of the user and not on clinically reliable and valid methodologies. Unintentionally, a clinician can categorize drainage on a S-AD as “scant/minimal” or “low” exudate when the fluid capacity of the S-AD is “large”.

Method: 20 wound clinicians first were asked to determine how many cc’s would constitute the amount of drainage on the S-AD continuum in terms of “scant,” “small/minimal,” “moderate,” and “large/copious.” Using a S-AD that holds a minimum of 500 cc exudate, they then were shown a S-AD dressing impregnated with fluid levels of 10 cc, 50 cc, 100 cc, 150 cc, and 200 cc and asked to describe the amount of drainage in the scant to large continuum in a random order.

Results: A disconnect was noted between the perception of exudate along a continuum on a S-AD dressing with high fluid retention capacity and that of the clinician, often underestimating the amount of fluid in the S-AD dressing.

Conclusion: The underestimation of fluid capacity of a S-AD dressing when documenting exudate amount can affect treatment decisions and S-AD availability under the Surgical Dressing Benefit. Clinicians using S-ADs should familiarize themselves with exudate retention ability and its clinical appearance in order to provide accurate medical record documentation.

Do the Velcro-Bungee Compress Garments Benefits Persist at 1 Year?

C. Jake Lambert, BAS; Jason MacLeod, CWCA; Christopher Rodriguez, PA-C; and Wendy Smiley, CSFA

A Cochrane review confirmed the critical importance of compression therapy for successful treatment of venous stasis disease. Compliance with compression stockings and multilayer compression therapy has been problematic; patients cite general discomfort/pain, slippage of stockings/wraps, and inability to place stockings, especially in the elderly. A previous long-term (7-year) cohort review of electronic medical records from 3144 patients showed only 33% of patients are compliant with compression garments therapy. 

We previously reviewed 23 patients’ (early) responses and compliance with the use of a Velcro-Bungee compression garment at 6 weeks in patients not compliant with traditional compression garments. Our early results demonstrated an increase in both compliance and length of utilization with Velcro-Bungee garments as compared to more traditional compression garments. After 1 year of therapy using Velcro-Bungee compression garments, patients were asked to complete the same questionnaire to see if the favorable responses persisted. Five (5) patients were lost to follow-up (2 deaths and 3 patients unavailable by phone or office visit). Of the remaining 18 patients, 3 admitted they were not wearing any kind of compression garment (noncompliant) and 4 patients had changed compression therapy (3 to traditional compression stockings and 1 to a zipper compression stocking).  Eleven (11) (61%) patients were still using the Velcro-Bungee garments at 1 year. Velcro patient responses are shown below. 

The early benefits noted at 6 weeks persisted at 1 year.

Scar Themes: A Qualitative Interview Study of Patient Quality of Life After Scarring

Ji-Cheng Hsieh, BA; Amanda Maisel, BS; Chitang Joshi, MD; and Robert Galiano, MD

The negative psychological effects of scarring are a pressing issue for wound healing clinicians. Effective scar scales necessitate patient interview data; otherwise scale items reflect what measures clinicians, not patients, deem appropriate. Available scar scales are lacking; a 2016 review by Mundy et al reported 4 major scar-specific scales with a measure of quality of life (Patient and Observer Scar Assessment Scale, Patient Scar Assessment Questionnaire, Problem Recognition in Self-Management, and the Bock Quality of Life Questionnaire) and found that as each scale had unique limitations, no scale is designed using patient interview data with measures of both appearance and symptoms. The Scar-Q attempts by Klassen et al address these concerns, utilizing patient interviews to draw common patient “themes” in scar appearance, psychosocial effects, and symptoms. A need remains to study themes in sexual well-being and career advancement, 2 areas that scarring affect.

Our qualitative interview study included 37 patients (9 [24%] male, 28 [76%] female), with keloid (5%), hypertrophic (14%), atrophic (11%), and linear (49%) scars primarily of surgical (68%) etiology. Most patients (41%) reported a “moderate” level of scar impact followed by a “low” level (30%). Most study participants (46%) were Caucasian, followed by African American (27%). The study protocol was submitted to and accepted by the Northwestern University IRB. Themes were organized into 8 domains. Domains such as psychosocial effects remained dominant, with themes such as “commonly thinking about a scar” referenced 56 times by 26 patients (patients referenced themes that were organized under sexual well-being and career). The impact of scarring on workplace interactions and networking was referenced 5 times by 3 patients, and feelings of insecurity specifically during intimacy were referenced 13 times by 7 patients. Although perhaps not as prevalent as psychosocial effects, the effects of scarring on career and sexual well-being remain present, and a comprehensive scar scale should touch upon these domains.

Body Image Among Women with Breast Wound: A Concept Analysis

Chantal Labrecque, RN, BSN, MSN

Introduction: The care and treatment of a wound involves both the physical and psychological aspects of scarring.

Purpose: This analysis aimed to define the concept of body image among adult women who have a breast wound. The literature surveyed demonstrated this subject is rarely explored.

Methodology: A concept analysis (Walker and Avant) was employed. This methodology, consisting of 8 steps, is accessible, simply structured, and concludes with the end concept made concrete and operational.

Results: The results of our analysis lead us to several definitions relative to body image. According to Chan, it is difficult to ascertain a specific definition of body image related to visible wounds; generally, the definition proposed by Price connects directly with our subject of interest. According to Walker and Avant, the characteristics of a concept are its attributes, its antecedents and its consequences. These elements have been extracted from the literature in order to define the characteristics of the concept in line with the subject of interest. A model case and a contrary case also were used to clarify and illustrate the body image concept. The empirical referents serve to make the concept operational and to diminish its level of abstraction. Two (2) means of specifically considering body image appear in the literature: Body Image Model (Price) and The Body Image Questionnaire (Bruchon-Schweitzer, 1987).

Conclusion: The concept analysis proposed in this work allowed us to transpose the concept of body image from an abstract level to a concrete, operational level, thereby fostering knowledge and understanding.

Use of Negative Pressure Wound Therapy with Instillation and Dwell Times for Complex Wound Management in a Cancer Care Setting

Dona Isaac, RN, MSN/ED, CWON

Introduction: Wound management represents a major health care cost and with inadequate intervention has a significant impact on patient quality of life. Oncological wounds have a delayed reaction in the wound healing cascade due to chemotherapy and radiation, treatments that are therapeutic to the destruction of cancer cells but have an adverse effect on tissue integrity and wound healing. An acute wound can easily progress to a chronic phase with inadequate wound care management. To address this problem at our cancer center, the unit-based wound ostomy nurse has utilized negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) for treatment of 6 patients with complex wounds and multiple comorbidities. 

Methods: NPWTi-d was initiated with instillation of normal saline or 0.125% hypochlorous solution, which was allowed to dwell for 3 to 20 minutes, followed by 2 to 3.5 hours of -125 mm Hg pressure. Dressing changes were performed every 2 to 3 days. Debridement, incision and drainage, and antibiotics were used as necessary.

Results: One (1) female and 5 males with an average age of 62 (range 53–78) years presented with the following wounds: surgical dehiscence (n = 3), pressure injury (n = 1), chronic seroma (n = 1), and abdominal wall abscess (n = 1). Malignancy was not detectable in any wounds. Patient comorbidities included diabetes, hypertension, and past treatment for cancers. NPWTi-d was applied for 1 to 2 weeks, after which the wounds exhibited a reduction in slough and an improvement in granulation tissue. Wounds were closed with a flap or transitioned to conventional NPWT before the patient was discharged home or to a rehabilitation clinic for outpatient recovery.

Conclusion: NPWTi-d is beneficial in the delivery, soak, and removal of topical solutions to cleanse the wound bed, thus creating a moist, closed wound environment conducive to healing. Using NPWTi-d supported the formation of a healthy wound bed and contributed to rapid, positive outcomes in this patient population.

Evaluation of a One-sided Wound Contact Layer to Treat Skin Tears in the Acute Care Setting

Elizabeth McElroy, MSN, CRNP, CWS, CWOCN-AP and Alicia Sherwood, PA-C

A skin tear is a common skin injury in the acute care setting, particularly in the elderly population. A multidisciplinary team at a Level 1 Trauma Center in eastern Pennsylvania identified discrepancies in treatment plans for patients with traumatic skin tears. Treatment plans included petrolatum gauze, nonadherent gauze, foam dressings, and antibiotic ointment with cover dressing. The trauma surgery team often assessed skin tears during daily rounds;  therefore, the dressing was lifted or removed daily. After collaborating with the CWOCN team at the hospital, the trauma team developed a new skin tear protocol for their patient population. The team began to treat skin tears with a 1-sided wound contact layer and secondary absorptive dressing. This allowed the providers to assess the skin tear daily while preventing wound bed disruption. Education began with the staff and providers in the emergency room, surgical intensive care unit, and orthopedic trauma units. Additional positive outcomes from this transition were improved clinician satisfaction, a cost savings, and a standardized method for treating skin tears at time of initial entry to the hospital.

Reducing Hematomas and Skin Complications

Laura Barnes, RN, MSN, CWCN, CCNS, APN, FNP

Background: Hematomas are caused by accumulation of clotted blood resulting from bleeding, usually associated with trauma, anticoagulation therapy, or surgically induced tissue injury. Hematomas can apply pressure on tissues, causing ischemia, resulting in secondary injury, contributing to the risk of dehiscence, serving as a nutrient source for infectious organisms, and slowing wound healing by prolonging inflammation. Six (6) patients presented with hematomas associated with open wounds or closed tissue injuries.

Methods: To prevent complications, polymeric membrane dressings (PMDs) were initiated with and without silver and nonsterile PMD wraps. PMDs have been shown to reduce inflammation and pain due to the capability of the dressing to control inflammation by helping focus healing at the primary injury site while reducing the development and spread of secondary injury. Patient 1: Surgical excision of an abnormal mole on posterior thigh. Patient 2: Tibial fracture complicated by compartment syndrome. Patient 3: Total knee replacement. Patient. 4: Calf athletic injury contusion. Patient. 5: Knee athletic injury; undetermined cause. Patient. 6: Knee/ lower leg trauma. PMDs were applied per manufacturer instructions and the change schedule ranged from every 2 to 3 days to once a week, and as needed.

Results: Major hematoma reduction occurred with PMDs for all patients. In addition, there was a decrease in swelling, inflammation and pain. For pt. 2, no wound dehiscence developed, and signs of infection decreased. PMDs helped to localize the inflammatory response to the zone of injury while reducing the spread of inflammation and swelling into surrounding tissues. All patients had resolution of their injury. The dressing was easy to apply and change.

Conclusions: PMDs helped: 1) resolve the hematomas for open and closed tissue injuries 2) heal the incision sites with no complications. Resolution resulted in faster recovery for the patients and return to daily activities.

Single-use Negative Pressure Wound Therapy Systems and the Pediatric Patient

Ferene Elsass, MSN, RN, CPN, CWON

Problem: Negative pressure wound therapy (NPWT) is a commonly used treatment in which a sponge is applied to a wound with negative pressure to augment healing. The process can be used on both chronic and acute wounds. The NPWT has multiple pieces and can be a large piece of equipment for pediatric patients. Although the treatment is effective, its use can lengthen a child’s hospital stay for closer patient monitoring or its size can make mobility more difficult for pediatric patients with a high activity level. Dressing changes occur several times a week and nurses are needed to provide care. Pediatric patients and their families are left anxious over the process and time spent away from home.

Purpose: The application of single-use NPWT for pediatric patient allows for sizing options ideal for smaller patients, allows for earlier discharge to home, and increases mobility related to the compact size.

Case Series: Demonstrate the use of a single use NPWT on a series of pediatric patients.

Results: The single-use NPWT was easy to apply and demonstrated no adverse side effect. The patient received the first dressing application in the hospital and followed up with the wound care team outpatient within the first week.  Patients followed up in 7 days if wound drainage was mild to moderate and within 3 days if the drainage was more substantial.  Patients required fewer dressing changes and parents were able to manage the therapy at home.  Four examples are presented in this poster. Single-use NPWT proved to be effective in all participating patients leading to resolution of wound, skin grafting or basic wound care performed at home. Therapy conclusion was observed within 3 applications or less, and patients in all cases reported ease in use and preference over other therapy modalities.