Pressure Injury Mitigation in Prolonged Care: A Randomized Noninferiority and Superiority Trial

INTRODUCTION

Combat casualties are at increased risk for pressure injuries (PIs) during prolonged casualty care. There is limited research on operational PI risk mitigation strategies. The purpose of this study was to (1) compare a prototype mattress (AirSupport) designed for operational conditions versus the foldable Talon litter and Warrior Evacuation Litter Pad (WELP) on PI risk factors and (2) determine whether the Talon + AirSupport pad was noninferior and superior to the Talon + WELP on skin interface pressure.

MATERIALS AND METHODS

Healthy adults (N = 85; 20 men and 65 women), aged 18 to 55 years, were stratified based on body fat percentage and randomized into three groups: Talon (n = 15), Talon + AirSupport (n = 35), and Talon + WELP (n = 35). The participants were asked to lie in a supine position for 1 hour. The outcomes included skin interface pressure (body surface areas: Sacrum, buttocks, occiput, and heels), sacral and buttock skin temperature and moisture, and discomfort and pressure. The study was approved by the University of Washington Institutional Review Board.

RESULTS

Aim 1: The Talon had significantly higher peak skin interface pressure versus the AirSupport and WELP on the sacrum, buttocks, occiput, and heels. Skin temperature increase over the 1-hour loaded period was significantly lower on Talon versus AirSupport or WELP, reflecting a lower temperature-induced ischemic load. There was no significant difference in skin moisture changes or discomfort between the surfaces. Aim 2: The upper confidence limits for the difference in skin interface pressure (all body surface areas) for AirSupport versus WELP were below 25 mm Hg, establishing noninferiority of the AirSupport to the WELP. AirSupport was also superior to WELP for the peak interface pressure on the sacrum, occiput, and heels but not on the buttocks. Skin temperature changes (sacrum or buttocks) were not significantly different between the AirSupport and WELP.

CONCLUSIONS

The Talon litter presents a PI risk because of increased skin interface pressure, and hence, immediate action is warranted. The decreased PI risk associated with the lower skin interface pressures on the AirSupport and WELP was offset by the higher skin temperature, which may add the equivalent of 20 to 30 mm Hg pressure to the ischemic burden. Thus, any pressure redistribution intervention must be evaluated with a consideration for skin interface pressure, temperature, and moisture. Data from this study were applied to a predictive model for skin damage. Under operational conditions where resources and the environment may limit patient repositioning, it would be expected that casualties would suffer skin damage within 2 to 5 hours, with the occiput as the highest risk area. The severity of predicted skin damage is lowest on the AirSupport, which is consistent with the noninferiority and superiority of the AirSupport mattress compared to the WELP and Talon. Operational utility: The AirSupport and WELP, which were both superior to the Talon, are operationally feasible solutions to mitigate PI risk. The smaller size of the Talon (2.7 kgs compressible) versus the WELP (5 kgs noncompressible) may make them appropriate for different levels of the operational setting.

Satisfaction and Barriers of Surgical Safety Checklist Implementation in a Nonmandatory Adoption Resource-Limited Country

OBJECTIVES

A surgical safety checklist has been a globally implemented and mandated adoption in several countries. However, its use is not mandatory in Thailand. This study aimed to evaluate the perceptions of surgical personnel on surgical complications and safety and to examine the satisfaction and barriers of surgical safety checklist implementation.

METHODS

A survey study was performed between November 2013 and February 2015 in 61 Thai hospitals. A questionnaire capturing demographics, perceptions related to surgical complications and safety, and the satisfaction and barriers of surgical safety checklist implementation was distributed to surgical personnel.

RESULTS

A total of 2024 surgical personnel were recruited. Nearly all of them reported experience or knowledge of an adverse surgical event (99.6%). Most thought that it could be preventable (98.2%) and quality care improvement could help reduce the occurrence of adverse events (97.7%). Overall, respondents reported a high level of satisfaction with the checklist (mean [SD] = 3.79 [0.71]). The three areas of highest satisfaction were benefit to the patient (mean [SD] = 4.11 [0.69]), benefit to the organization (mean [SD] = 4.05 [0.68]), and reduction in adverse events (mean [SD] = 4.02 [0.69]). Overall, the barrier for implementation of the checklist was rated as moderate (mean [SD] = 2.52 [0.99]). However, the means of barriers in each period, sign in, time out, and sign out, were rated as low (means [SD] = 2.41 [1.07], 2.50 [1.03], and 2.34 [1.01], respectively).

CONCLUSIONS

The data document that the satisfaction with the checklist are fairly high. However, some barriers were identified. Efforts to increase understanding through more rigorous policy enforcement and strategic support may lead to improving the checklist implementation.

Reducing the Risk for Pressure Injury During Combat Evacuation

BACKGROUND

Combat casualties undergoing aeromedical evacuation are at increased risk for pressure injuries. The risk factors pressure and shear are potentially modifiable via solutions appropriate for en route care.

OBJECTIVES

To compare transcutaneous oxygen levels and skin temperatures in healthy participants under offloaded (side lying) and loaded (supine or supine with 30° backrest elevation) under 4 conditions: control (no intervention), Mepilex sacral and heel dressings, LiquiCell pad, and Mepilex plus LiquiCell.

METHODS

Participants were randomly assigned to 4 groups according to ideal body weight. Backrest positions were randomized. Transcutaneous oxygen level and temperature were measured on the sacrum and the heel; skin interface pressure was measured with an XSensor pressure imaging system. Measurements were obtained for 5 minutes at baseline (offloaded), 40 minutes with participants supine, and 15 minutes offloaded.

RESULTS

In the 40 healthy participants, interface pressure, transcutaneous oxygen level, and skin temperature did not differ between the 4 groups. Peak interface pressures were approximately 43 mm Hg for the sacrum and 50 mm Hg for the heel. Sacral transcutaneous oxygen level differed significantly between unloaded (mean, 79 mm Hg; SD, 16.5) and loaded (mean, 57 mm Hg; SD, 25.2) conditions (P < .001) in a flat position (mean, 85.2 mm Hg; SD, 13.6) and with 30° backrest elevation (mean, 66.7 mm Hg; SD, 24.2) conditions (P < .001). Results for the heels and the sacrum were similar. Sacral skin temperature increased significantly across time (approximately 1.0°C).

CONCLUSIONS

The intervention strategies did not differ in prevention of pressure injuries.

An exploration of surgical team perceptions toward implementation of surgical safety checklists in a non-native English-speaking country

BACKGROUND

In-depth information on the success and failure of implementing the World Health Organization surgical safety checklist (SSC) has been questioned in non-native English-speaking countries. This study explored the experiences of SSC implementation and documented barriers and strategies to improve SSC implementation.

METHODS

A qualitative study was performed in 33 Thai hospitals. The information from focus group discussions with 39 nurses and face-to-face, in-depth interviews with 50 surgical personnel was analyzed using content analysis.

RESULTS

Major barriers were an unclear policy, inadequate personnel, refusals and resistance from the surgical team, English/electronic SSC, and foreign patients. The key strategies to improve SSC implementation were found to be policy management, training using role-play and station-based deconstruction, adapting SSC implementation suitable for the hospital's context, building self-awareness, and patient involvement.

CONCLUSION

The barriers of SSC were related to infrastructure and patients. Effective policy management, teamwork and individual improvement, and patient involvement may be the keys to successful SSC implementation.

Noninvasive Blood Pressure Monitoring and Prediction of Fluid Responsiveness to Passive Leg Raising

BACKGROUND

Intravenous fluid boluses are administered to patients in shock to improve tissue hypoperfusion. However, fluid boluses result in clinically significant stroke volume increases in only about 50% of patients. Hemodynamic responses to passive leg raising measured with invasive and minimally invasive methods are accurate predictors of fluid responsiveness. However, few studies have used noninvasive blood pressure measurement to evaluate responses to passive leg raising.

OBJECTIVE

To determine if passive leg raising-induced increases in pulse pressure or systolic blood pressure can be used to predict clinically significant increases in stroke volume index in healthy volunteers.

METHODS

In a repeated-measures study, hemodynamic measurements were obtained in 30 healthy volunteers before, during, and after passive leg raising. Each participant underwent the procedure twice.

RESULTS

In the first test, 20 participants (69%) were responders (stroke volume index increased by ≥ 15%); 9 (31%) were nonresponders. In the second test, 15 participants (50%) were responders and 15 (50%) were nonresponders. A passive leg raising-induced increase in pulse pressure of 9% or more predicted a 15% increase in stroke volume index (sensitivity, 50%; specificity, 44%). There was no association between passive leg raising-induced changes in systolic blood pressure and fluid responsiveness.

CONCLUSION

A passive leg raising-induced change in stroke volume index measured by bioreactance differentiated fluid responders and nonresponders. Pulse pressure and systolic blood pressure measured by oscillometric noninvasive blood pressure monitoring were not sensitive or specific predictors of fluid responsiveness in healthy volunteers.

Passive Leg-Raising and Prediction of Fluid Responsiveness: Systematic Review

Fluid boluses are often administered with the aim of improving tissue hypoperfusion in shock. However, only approximately 50% of patients respond to fluid administration with a clinically significant increase in stroke volume. Fluid overload can exacerbate pulmonary edema, precipitate respiratory failure, and prolong mechanical ventilation. Therefore, it is important to predict which hemodynamically unstable patients will increase their stroke volume in response to fluid administration, thereby avoiding deleterious effects. Passive leg-raising (lowering the head and upper torso from a 45° angle to lying supine [flat] while simultaneously raising the legs to a 45° angle) is a transient, reversible autotransfusion that simulates a fluid bolus and is performed to predict a response to fluid administration. The article reviews the accuracy, physiological effects, and factors affecting the response to passive-leg raising to predict fluid responsiveness in critically ill patients.

Patterns of Hand Grip Strength and Detection of Strength Loss in Patients Undergoing Bone Marrow Transplantation: A Feasibility Study

PURPOSE/OBJECTIVES

To determine the feasibility of measuring hand grip strength (HGS) daily in a population of recipients of bone marrow transplantation (BMT), to describe changes in strength measured by HGS, and to describe relationships between laboratory values (hematocrit, hemoglobin, and absolute neutrophil count) and HGS.
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DESIGN

Prospective, longitudinal, repeated measures, within subject.
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SETTING

Inpatient units at the University of Washington Medical Center in Seattle.
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SAMPLE

33 patients admitted in preparation for BMT or for complications from BMT.
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METHODS

HGS measured on admission and daily.
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MAIN RESEARCH VARIABLES

HGS, absolute neutrophil count, hemoglobin, and hematocrit.
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FINDINGS

Participants found HGS testing to be relatively easy. Average time to complete testing was 7.2 minutes (SD = 1.95). Nineteen experienced 20% or greater decline in HGS during hospitalization, with nine experiencing decline during the conditioning phase. Age, gender, and hemoglobin correlated with HGS. Strength loss was more likely in those undergoing allogeneic compared to autologous BMT.
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CONCLUSIONS

A majority of patients experienced strength decline during BMT, with a subgroup declining during conditioning. A positive relationship existed between HGS and hemoglobin and hematocrit in participants admitted for conditioning for BMT.
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IMPLICATIONS FOR NURSING

Weakness increases risk for falls. Patients may experience as much as 50% strength loss during the course of hospitalization for BMT. Strength loss occurs in the conditioning phase for some patients.

Lifestyle Physical Activity for Individuals with Spinal Cord Injury: A Pilot Study

Purpose.

To evaluate the acceptability and feasibility of a lifestyle physical activity program for people with spinal cord injury (SCI).

Methods.

Sixteen nonexercising adult volunteers with SCI participated in a single group pre-post–test of the “Be Active in Life Program” comprising stage-matched educational materials, home visit by a nurse, construction of a personal plan to increase activity, and four follow-up phone calls. Program acceptability, stage of change, barriers to health-promoting activities, abilities for health practices, health, depression, and muscle strength were rated. Physical activity was monitored using actigraphy and a self-report record.

Results.

Participants rated the program positively, although some preferred a structured exercise approach. Eighty-one percent of participants progressed in stage of change and 60% increased physical activity. There were significant changes in motivational barriers, exercise self-efficacy, self-rated health, and muscle strength.

Discussion.

Lifestyle physical activity is feasible and acceptable and could be effective in promoting greater physical activity among people with SCI.

The Effect of Early Postoperative Physical Activity on Tissue Oxygen and Wound Healing

Background. Supplemented postoperative activity was compared to standard activity for effects on wound healing, subcutaneous tissue perfusion, and oxygen (PscO2 ) following hip replacement (THR).

Methods. 58 patients were randomized to standard post-THR activity (N = 27) or supplemental activity (N = 31) (arm and leg exercises, walking protocol). PscO2 was measured with a microelectrode/tonometer system and perfusion determined by oxygen response. Healing was evaluated by (1) tissue cellularity, (2) mRNA for pro collagen, (3) hydroxyproline, and (4) DNA content obtained from a subcutaneous implant removed on the 7th postoperative day.

Results. Activity significantly increased DNA levels, but did not increase PscO2 , perfusion, cellularity, or collagen measures.

Conclusions. Healing measures were not improved with increased activity levels. However, activity did not reduce PscO2 or wound healing. The majority of patients adhered to additional activity and tolerated the protocol well. Increased activity was associated with earlier discharge, suggesting other recovery-related benefits.

Prevalence and risk factors of needlestick injuries, sharps injuries, and blood and body fluid exposures among operating room nurses in Thailand

BACKGROUND

Operating room nurses are at high risk for occupational exposure to bloodborne pathogens. This study examined the prevalence of and risk factors for needlestick injuries (NSIs), sharps injuries (SIs), and blood and body fluid exposures (BBFEs) among operating room nurses in Thai hospitals.

METHODS

A cross-sectional study was performed in 247 Thai hospitals. Questionnaires eliciting demographic data and information on injury occurrence and risk factors were distributed to 2500 operating room nurses, and 2031 usable questionnaires were returned, for a response rate of 81.2%. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using multiple logistic regression analysis.

RESULTS

The prevalence of NSIs, SIs, and BBFEs was 23.7%, 9.8%, and 40.0%, respectively. Risk factors for NSIs were training without practice (OR, 1.67; 95% CI, 1.29-2.17), haste (OR, 4.81; 95% CI, 3.41-6.79), lack of awareness (OR, 1.36; 95% CI, 1.04-1.77), inadequate staffing (OR, 1.60; 95% CI, 1.21-2.11), and outdated guidelines (OR, 1.69; 95% CI, 1.04-2.74). One risk factor was identified for SIs: haste (OR, 2.43; 95% CI, 1.57-3.76). Risk factors for BBFEs were long working hours per week (OR, 2.07; 95% CI, 1.06-4.04), training without practice (OR, 1.55; 95% CI, 1.25-1.91), haste (OR, 1.66; 95% CI, 1.30-2.13), lack of awareness (OR, 1.54; 95% CI, 1.22-1.95), not wearing protective equipment (OR, 1.61; 95% CI, 1.26-2.06), and inadequate staffing (OR, 1.63; 95% CI, 1.26-2.11).

CONCLUSION

This study highlights the high prevalence of NSIs, SIs, and BBFEs among Thai operating room nurses. Preventable risk factors were identified. Appropriate guidelines, adequate staffing, proper training, and self-awareness may reduce these occurrences.

The Effects of Local Warming on Surgical Site Infection

BACKGROUND

Surgical site infections (SSI) account for a major proportion of hospital-acquired infections. They are associated with longer hospital stay, readmissions, increased costs, mortality, and morbidity. Reducing SSI is a goal of the Surgical Care Improvement Project and identifying interventions that reduce SSI effectively is of interest. In a single-blinded randomized controlled trial (RCT) we evaluated the effect of localized warming applied to surgical incisions on SSI development and selected cellular (immune, endothelial) and tissue responses (oxygenation, collagen).

METHODS

After Institutional Review Board approval and consent, patients having open bariatric, colon, or gynecologic-oncologic related operations were enrolled and randomly assigned to local incision warming (6 post-operative treatments) or non-warming. A prototype surgical bandage was used for all patients. The study protocol included intra-operative warming to maintain core temperature ≥36°C and administration of 0.80 FIO2. Patients were followed for 6 wks for the primary outcome of SSI determined by U.S. Centers for Disease Control (CDC) criteria and ASEPSIS scores (additional treatment; presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues; isolation of bacteria; and duration of inpatient stay). Tissue oxygen (PscO2) and samples for cellular analyses were obtained using subcutaneous polytetrafluoroethylene (ePTFE) tubes and oxygen micro-electrodes implanted adjacent to the incision. Cellular and tissue ePTFE samples were evaluated using flow cytometry, immunohistochemistry, and Sircol™ collagen assay (Biocolor Ltd., Carrickfergus, United Kingdom).

RESULTS

One hundred forty-six patients participated (n=73 per group). Study groups were similar on demographic parameters and for intra-operative management factors. The CDC defined rate of SSI was 18%; occurrence of SSI between groups did not differ (p=0.27). At 2 wks, warmed patients had better ASEPSIS scores (p=0.04) but this difference was not observed at 6 wks. There were no significant differences in immune, endothelial cell, or collagen responses between groups. On post-operative days one to two, warmed patients had greater PscO2 change scores with an average PscO2 increase of 9-10 mm Hg above baseline (p<0.04).

CONCLUSIONS

Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and FIO2 level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. PscO2 increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions.

Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?

PURPOSE

The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.

METHODS

From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.

RESULTS

The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001).

CONCLUSIONS

An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.

Correlates of physical activity in adults with mobility limitations

This study identified the correlates of objectively and subjectively measured physical activity in adult wheelchair users. Fifty participants wore an activity monitor for a week and completed a questionnaire about factors associated with physical activity. Objectively measured activity correlated significantly with body mass index. Subjectively measured activity correlated significantly with age, stage of change, health, healthcare providers discussing exercise, and social support for exercise. Research on the effect of body mass index on activity in this population is needed. Intervention planners should plan programs that place emphasis on modifying the social environment (including healthcare providers) and removing attitudinal barriers.

Overview: acute and chronic wounds

Knowledge of normal wound healing and the changes associated with chronic wounds have advanced significantly. Distinct characteristics identified through basic and clinical studies are found in nonhealing wounds, including bacterial and growth factor imbalances, increased inflammatory responses, and proteolytic forces that tip the balance toward tissue degradation rather than repair. This article describes the alterations that reduce healing and that also have important implications for the management of chronic wounds and presents a focus for future developments in wound therapy.

Treating chronic and acute wounds with warming: Review of the science and practice implications

Systemic and local warming of tissue produces physiologic and cellular responses in the local wound environment conducive to wound healing. The use of warming to treat wounds is not a new idea, but the ability to deliver warming with controlled temperatures and conditions is a recent development. This article reviews basic science and clinical studies of active systemic and local warming and the reported effects on wound physiology, healing, and rate of infection in chronic and acute wounds. Twelve clinical studies evaluating active warming were identified. Existing data demonstrate improved healing outcomes and infection reduction associated with active warming therapy. Practical implications of using active warming therapy, including appropriate wound types and settings, obtaining product, guidelines for administering therapy, patient teaching, and cost-benefit information, are discussed.

Effects of an augmented postoperative fluid protocol on wound healing in cardiac surgery patients

BACKGROUND

Cardiac surgery patients are vulnerable to hypoperfusion postoperatively and often have subcutaneous tissue oxygen tension less than 50 mm Hg. Hypovolemia most likely contributes to this hypoperfusion and may lead to impaired wound healing.

OBJECTIVES

To determine if a modified postoperative fluid replacement protocol would result in improved tissue oxygen tension, blood flow, and healing in cardiothoracic surgery patients.

METHODS

A total of 166 cardiac surgery patients, 18 to 90 years old, participated in a randomized, 2-group, repeated-measures study. The experimental group received fluid augmentation during the first 36 hours after surgery; the control group received standard postoperative replacement fluids. Subcutaneous tissue oxygen tension and temperature were measured 8, 18, and 36 hours after surgery. Tissue cellularity and accumulation of hydroxyproline were evaluated in tissue obtained from subcutaneous expanded polytetrafluoroethylene tubes. Wound complications were evaluated by using the ASEPSIS Wound Scoring System.

RESULTS

Tissue oxygen levels, tissue cellularity, and accumulation of hydroxyproline were similar in the 2 groups. A negative correlation (P = .01) existed between higher tissue oxygen values and lower (better) ASEPSIS leg wound scores. More than 80% of the patients had tissue oxygen levels of 50 mm Hg or less at each time of measure. Many values were 30 to 40 mm Hg less than the ideal for control of bacteria and healing.

CONCLUSIONS

The frequency of low oxygen levels is consistent with data from earlier studies. Determination of other interventions to improve subcutaneous tissue perfusion in cardiac surgery patients is needed.

Effects of an Augmented Postoperative Fluid Protocol on Wound Healing in Cardiac Surgery Patients

• Background Cardiac surgery patients are vulnerable to hypoperfusion postoperatively and often have subcutaneous tissue oxygen tension less than 50 mm Hg. Hypovolemia most likely contributes to this hypoperfusion and may lead to impaired wound healing.

• Objective To determine if a modified postoperative fluid replacement protocol would result in improved tissue oxygen tension, blood flow, and healing in cardiothoracic surgery patients.

• Methods A total of 166 cardiac surgery patients, 18 to 90 years old, participated in a randomized, 2-group, repeated-measures study. The experimental group received fluid augmentation during the first 36 hours after surgery; the control group received standard postoperative replacement fluids. Subcutaneous tissue oxygen tension and temperature were measured 8, 18, and 36 hours after surgery. Tissue cellularity and accumulation of hydroxyproline were evaluated in tissue obtained from subcutaneous expanded polytetrafluoroethylene tubes. Wound complications were evaluated by using the ASEPSIS Wound Scoring System.

• Results Tissue oxygen levels, tissue cellularity, and accumulation of hydroxyproline were similar in the 2 groups. A negative correlation (P = .01) existed between higher tissue oxygen values and lower (better) ASEPSIS leg wound scores. More than 80% of the patients had tissue oxygen levels of 50 mm Hg or less at each time of measure. Many values were 30 to 40 mm Hg less than the ideal for control of bacteria and healing.

• Conclusions The frequency of low oxygen levels is consistent with data from earlier studies. Determination of other interventions to improve subcutaneous tissue perfusion in cardiac surgery patients is needed.

Treatment of pressure ulcers with noncontact normothermic wound therapy: healing and warming effects

OBJECTIVE

This study compared healing rates in stage III and IV pressure ulcers treated with noncontact normothermic wound therapy or moist dressings. Periwound temperature changes with noncontact normothermic wound therapy were evaluated.

DESIGN

This 8-week, prospective, randomized clinical trial evaluated linear rate of healing of the wound edge and periwound temperature changes during the 1-hour warming treatment and for 15 minutes after warming.

SETTING AND SUBJECTS

Forty subjects referred from primary care providers, home care providers, acute care facilities, and long-term care facilities were enrolled in the study. Twenty-nine subjects completed the trial (14 received standard care, and 15 received noncontact normothermic wound therapy).

INSTRUMENTS

Ulcers were measured with acetate tracings, digital and Polaroid photography, and Pressure Sore Status Tool evaluations. The linear rate of healing was determined with use of computerized planimetry. Periwound temperatures were recorded with use of a Cole Parmer thermometer YSI 400 series.

METHODS

Subjects were evaluated weekly. Subjects randomly assigned to noncontact normothermic wound therapy received 3 treatments daily, during which the dressing was warmed to 38 degrees C for 1 hour. Subjects in the standard care group were treated with dressings that were moisture retentive and provided absorption as needed.

RESULTS

The two groups were statistically similar with regard to baseline and wound characteristics. The linear rate of healing was significantly faster in the group treated with noncontact normothermic wound therapy (Mann-Whitney U test = 47, P =.01). On average, periwound temperatures increased 2.4 degrees C at the end of warming (1 hour), a significant increase above baseline values (P =.001).

CONCLUSIONS

The healing rate was significantly increased with noncontact normothermic wound therapy treatment. Periwound temperature increased significantly after 1 hour of warming, achieving levels approximating normothermia. Healing effects associated with noncontact normothermic wound therapy may be related to several mechanisms, including improvements in perfusion, oxygen supply, and cellular activity in response to warming.

Tissue and wound healing effects of short duration postoperative oxygen therapy

The purpose of this study was to determine the effects of 28% oxygen given in the first 36 hours after surgery on tissue oxygen, collagen deposition, and clinical healing outcomes. Twenty-four subjects having cervical spine surgical procedures participated in a randomized, repeated-measures pilot study of tissue and healing effects of postoperative supplemental oxygen. The treatment group (n = 13) received 28% oxygen for the first 36 postoperative hours, whereas the control group (n = 11) was maintained on room air. Subcutaneous tissue oxygen and temperature were measured at intervals up to 36 hours postsurgery. Wound healing was evaluated by hydroxyproline content in a subcutaneous polytetrafluoroethylene tube removed on the 7th postoperative day. Clinical outcomes were evaluated for the 30 days post-hospital discharge. Subjects in the treatment group had significantly higher tissue oxygen tension overall, and at postoperative hours 1, 2, 18, and 36, with mean values 10 to 20 mm Hg higher than control subjects. Significant differences were not found in hydroxyproline levels or clinical wound outcome measures. Low level, short duration, supplemental oxygen increased and sustained wound tissue oxygen and was well tolerated by subjects. Larger studies of populations at risk for wound complications are needed to investigate variables of dose and duration of oxygen therapy in relation to clinical and cellular wound healing outcomes.

Nurses' knowledge of wound irrigation and pressures generated during simulated wound irrigation

OBJECTIVE

Our objective was to describe nurses' knowledge of wound irrigation and their ability to produce appropriate irrigation pressures established by the US Agency for Healthcare Research and Quality (AHRQ) during simulated procedures.

SUBJECTS AND SETTING

A convenience sample of 28 registered nurses and licensed practical nurses from a university medical center in the Northwest United States comprised the subjects.

METHODS

Participants were asked to complete a demographic data sheet and a questionnaire related to wound irrigation and to perform 2 simulated wound irrigations. The questionnaire developed for the study contained 9 questions about general knowledge of wound irrigation and 9 questions about wound irrigation technique. A device to measure the pressures generated by the participants during simulated wound irrigation was developed and calibrated using a transducer calibrated by the National Institute of Science and Technology.

RESULTS

Participants' scores were high on items querying general knowledge of wound irrigation but lower on questions relating to irrigation technique. Thirteen participants achieved irrigation pressures within the guidelines established by the AHRQ, 14 fell below the guidelines, and 1 produced pressures exceeding the guidelines.

CONCLUSION

The majority of nurses participating in this small study had some difficulty answering questions relating to wound irrigation technique. In addition, performance on simulated irrigation showed that the majority were not able to generate pressures in the recommended range. Nursing professionals and educators should be aware of these knowledge and performance issues and incorporate educational content and experiences in nursing programs designed to aid nurses in improving wound irrigation practice.

Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds

Tissue injury is common among patients in acute care settings. The subsequent response to injury, wound healing, follows an intricate but well-defined sequence that, under normal conditions, proceeds to satisfactory repair. However, because of the complexity of the healing response, several factors can intervene to impair normal healing. As a better understanding of how diverse factors influence healing is gained, the use of interventions that modulate these factors becomes possible and potentially beneficial. This article reviews knowledge of perfusion, nutrition, and stress as they relate to healing in patients experiencing acute wounds. Therapeutic implications based on current research are discussed.

Identifying and evaluating wound infection

Wound infection is a serious problem in the home care patient. Early detection of infection, prompt treatment, and continuous surveillance are pivotal to elimination of the infection and prevention of complications. This article addresses identification of wound infection in postsurgical and chronic wounds based on data obtained from the patient's history, physical examination, and diagnostic tests. Appreciating the overt and subtle signs and symptoms of wound infection and acting on them is critical to timely diagnosis and treatment.