Search

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.

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.

Hospital-acquired pressure injuries are a serious problem among critical care patients. Some can be prevented by using measures such as specialty beds, which are not feasible for every patient because of costs. However, decisions about which patient would benefit most from a specialty bed are difficult because results of existing tools to determine risk for pressure injury indicate that most critical care patients are at high risk.To develop a model for predicting development of pressure injuries among surgical critical care patients.Data from electronic health records were divided into training (67%) and testing (33%) data sets, and a model was developed by using a random forest algorithm via the R package "randomforest."Among a sample of 6376 patients, hospital-acquired pressure injuries of stage 1 or greater (outcome variable 1) developed in 516 patients (8.1%) and injuries of stage 2 or greater (outcome variable 2) developed in 257 (4.0%). Random forest models were developed to predict stage 1 and greater and stage 2 and greater injuries by using the testing set to evaluate classifier performance. The area under the receiver operating characteristic curve for both models was 0.79.This machine-learning approach differs from other available models because it does not require clinicians to input information into a tool (eg, the Braden Scale). Rather, it uses information readily available in electronic health records. Next steps include testing in an independent sample and then calibration to optimize specificity.

Antibiotic prophylaxis is a key component of the prevention of surgical site infection (SSI). Failure to manage antibiotic prophylaxis effectively may increase the risk of SSI. This study aimed to examine the effects of antibiotic prophylaxis on SSI risk.A retrospective cohort study was conducted among patients having general surgery between May 2012 and June 2015 at the University of Washington Medical Center. Peri-operative data extracted from hospital databases included patient and operation characteristics, intra-operative medication and fluid administration, and survival outcome. The effects of antibiotic prophylaxis and potential factors on SSI risk were estimated using multiple logistic regression and were expressed as risk ratios (RRs).A total of 4,078 patients were eligible for analysis. Of these, 180 had an SSI. Mortality rates within and after 30 days were 0.8% and 0.3%, respectively. Improper antibiotic redosing increased the risk of SSI (RR 4.61; 95% confidence interval [CI] 1.33-15.91). Other risk factors were in-patient status (RR 4.05; 95% CI 1.69-9.66), smoking (RR 1.63; 95% CI 1.03-2.55), emergency surgery (RR 1.97; 95% CI 1.26-3.08), colectomy (RR 3.31; 95% CI 1.19-9.23), pancreatectomy (RR 4.52; 95% CI 1.53-13.39), proctectomy (RR 5.02; 95% CI 1.72-14.67), small bowel surgery (RR 6.16; 95% CI 2.13-17.79), intra-operative blood transfusion500 mL (RR 2.76; 95% CI 1.45-5.26), and multiple procedures (RR 1.40; 95% CI 1.01-1.95).These data demonstrate that failure to redose prophylactic antibiotic during long operations increases the risk of SSI. Strengthening a collaborative surgical quality improvement program may help to eradicate this risk.

Purpose The purpose of this article is to describe the outcomes of a collaborative initiative to share data across five schools of nursing in order to evaluate the feasibility of collecting common data elements (CDEs) and developing a common data repository to test hypotheses of interest to nursing scientists. This initiative extended work already completed by the National Institute of Nursing Research CDE Working Group that successfully identified CDEs related to symptoms and self-management, with the goal of supporting more complex, reproducible, and patient-focused research. Design Two exemplars describing the group's efforts are presented. The first highlights a pilot study wherein data sets from various studies by the represented schools were collected retrospectively, and merging of the CDEs was attempted. The second exemplar describes the methods and results of an initiative at one school that utilized a prospective design for the collection and merging of CDEs. Methods Methods for identifying a common symptom to be studied across schools and for collecting the data dictionaries for the related data elements are presented for the first exemplar. The processes for defining and comparing the concepts and acceptable values, and for evaluating the potential to combine and compare the data elements are also described. Presented next are the steps undertaken in the second exemplar to prospectively identify CDEs and establish the data dictionaries. Methods for common measurement and analysis strategies are included. Findings Findings from the first exemplar indicated that without plans in place a priori to ensure the ability to combine and compare data from disparate sources, doing so retrospectively may not be possible, and as a result hypothesis testing across studies may be prohibited. Findings from the second exemplar, however, indicated that a plan developed prospectively to combine and compare data sets is feasible and conducive to merged hypothesis testing. Conclusions Although challenges exist in combining CDEs across studies into a common data repository, a prospective, well-designed protocol for identifying, coding, and comparing CDEs is feasible and supports the development of a common data repository and the testing of important hypotheses to advance nursing science. Clinical relevance Incorporating CDEs across studies will increase sample size and improve data validity, reliability, transparency, and reproducibility, all of which will increase the scientific rigor of the study and the likelihood of impacting clinical practice and patient care.

The prevalence and incidence of chronic venous leg ulcers (CVLUs) are increasing worldwide, as are the associated financial costs. Although it has long been known that their underlying etiology is venous insufficiency, the molecular aspects of healing versus nonhealing, as well as the psychoneurologic symptoms (PNS; pain, cognitive dysfunction, fatigue, depression, and anxiety) associated with CVLUs remain understudied. In this biobehaviorally focused review, we aim to elucidate the complex mechanisms that link the biological and molecular aspects of CLVUs with their PNS. Innovations in “omics” research have increased our understanding of important wound microenvironmental factors (e.g., inflammation, microbial pathogenic biofilm, epigenetic processes) that may adversely alter the wound bed’s molecular milieu so that microbes evade immune detection. Although these molecular factors are not singularly responsible for wound healing, they are major components of wound development, nonhealing, and PNS that, until now, have not been amenable to systematic study, especially over time. Further, this review explores our current understanding of the molecular mechanisms by which the immune activation that contributes to the development and persistence of CVLUs also leads to the development, persistence, and severity of wound-related PNS. We also make recommendations for future research that will expand the field of biobehavioral wound science. Biobehavioral research that focuses on the interrelated mechanisms of PNS will lead to symptom-management interventions that improve quality of life for the population burdened by CVLUs.

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.

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.

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.

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).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).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 (p0.04).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.

Purpose To enhance the learner's competence with knowledge of changes in classifications of chronic lower limb wound codes from ICD-9-CM to ICD-10-CM in patients with diabetes. Target audience This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. Objectives After participating in this educational activity, the participant should be better able to:1. Identify the upcoming transition date and coding differences of ICD-9-CM and ICD-10-CM coding.2. Interpret the author's study population, methods, and design.3. Summarize the author's study findings comparing ICD-9-CM coding to ICD-10-CM coding. Objective To determine the sensitivity and specificity of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for individuals with diabetes and foot ulcers. Design and methods Wound care providers and researchers are concerned about the potential impacts when the United States transitions from ICD-9-CM to ICD-10-CM. To identify the impact on diabetic foot ulcers, health history and wound variables were prospectively assessed with criterion-standard data from a prospective study of 49 patients with 65 foot ulcer episodes representing 81 incident foot ulcers. The ICD-9-CM and ICD-10-CM code sets were mapped to correctly classify individuals with diabetes and foot ulcers. Results Frequencies for health history variables were similar in both systems. The ICD-9 code did not capture any data on laterality (left or right) or ulcer depth/severity. The ICD-9 captured 69 of 81 incident ulcers (85%) and 94% of heel and midfoot ulcers, whereas the ICD-10 code captured 78 of 81 incident ulcers (96%) and all incident heel or midfoot ulcers. Sensitivity and specificity for ulcer characteristics were consistently lower in ICD-9 than in ICD-10. Conclusions The ICD-9 and ICD-10 are similar for data capture on health history variables, but wound variables are captured more accurately using ICD-10. The increased specificity of ICD-10 for ulcer location and severity improves identification and tracking ulcers during an episode of care.

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. .Prospective, longitudinal, repeated measures, within subject. .Inpatient units at the University of Washington Medical Center in Seattle. .33 patients admitted in preparation for BMT or for complications from BMT. .HGS measured on admission and daily. .HGS, absolute neutrophil count, hemoglobin, and hematocrit. .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. .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. .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.

Background Microbiome-directed therapies are increasingly used preoperatively and postoperatively to improve postoperative outcomes. Recently, the effectiveness of probiotics, prebiotics, and synbiotics in reducing postoperative complications (POCs) has been questioned. This systematic review aimed to examine and rank the effectiveness of these therapies on POCs in adult surgical patients. Methods We searched for articles from PubMed, Embase, Cochrane, Web of Science, Scopus, and CINAHL plus. From 2002 to 2015, 31 articles meeting the inclusion criteria were identified in the literature. Risk of bias and heterogeneity were assessed. Network meta-analyses (NMA) were performed using random-effects modeling to obtain estimates for study outcomes. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated. We then ranked the comparative effects of all regimens with the surface under the cumulative ranking (SUCRA) probabilities. Results A total of 2,952 patients were included. We found that synbiotic therapy was the best regimen in reducing surgical site infection (SSI) (RR = 0.28; 95% CI, 0.12-0.64) in adult surgical patients. Synbiotic therapy was also the best intervention to reduce pneumonia (RR = 0.28; 95% CI, 0.09-0.90), sepsis (RR = 0.09; 95% CI, 0.01-0.94), hospital stay (mean = 9.66 days, 95% CI, 7.60-11.72), and duration of antibiotic administration (mean = 5.61 days, 95% CI, 3.19-8.02). No regimen significantly reduced mortality. Conclusions This network meta-analysis suggests that synbiotic therapy is the first rank to reduce SSI, pneumonia, sepsis, hospital stay, and antibiotic use. Surgeons should consider the use of synbiotics as an adjunctive therapy to prevent POCs among adult surgical patients. Increasing use of synbiotics may help to reduce the use of antibiotics and multidrug resistance.

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.

The purpose of this article is to describe the outcomes of a collaborative initiative to share data across five schools of nursing in order to evaluate the feasibility of collecting common data elements (CDEs) and developing a common data repository to test hypotheses of interest to nursing scientists. This initiative extended work already completed by the National Institute of Nursing Research CDE Working Group that successfully identified CDEs related to symptoms and self-management, with the goal of supporting more complex, reproducible, and patient-focused research.Two exemplars describing the group's efforts are presented. The first highlights a pilot study wherein data sets from various studies by the represented schools were collected retrospectively, and merging of the CDEs was attempted. The second exemplar describes the methods and results of an initiative at one school that utilized a prospective design for the collection and merging of CDEs.Methods for identifying a common symptom to be studied across schools and for collecting the data dictionaries for the related data elements are presented for the first exemplar. The processes for defining and comparing the concepts and acceptable values, and for evaluating the potential to combine and compare the data elements are also described. Presented next are the steps undertaken in the second exemplar to prospectively identify CDEs and establish the data dictionaries. Methods for common measurement and analysis strategies are included.Findings from the first exemplar indicated that without plans in place a priori to ensure the ability to combine and compare data from disparate sources, doing so retrospectively may not be possible, and as a result hypothesis testing across studies may be prohibited. Findings from the second exemplar, however, indicated that a plan developed prospectively to combine and compare data sets is feasible and conducive to merged hypothesis testing.Although challenges exist in combining CDEs across studies into a common data repository, a prospective, well-designed protocol for identifying, coding, and comparing CDEs is feasible and supports the development of a common data repository and the testing of important hypotheses to advance nursing science.Incorporating CDEs across studies will increase sample size and improve data validity, reliability, transparency, and reproducibility, all of which will increase the scientific rigor of the study and the likelihood of impacting clinical practice and patient care.

Background: A clinical skills laboratory enhances nursing skills that can be translated to real professional practice. However, effective laboratory learning material that facilitates learners to achieve learning objectives may be inadequate in resource-limited settings. This study aimed to develop models for practicing wound dressing changes and to evaluate the quality of the model and user satisfaction. Methods: The study was conducted in three phases: 1) preparing for model development, 2) model development, and 3) evaluation of the quality of the model and user satisfaction. Convenience sampling was employed to recruit both recruited both nursing instructors and nursing students, 30, 10 and 271 participants in the first, second, and third phases, respectively. Focus group discussions were performed to gain ideas and opinions for developing the models. A Likert scale questionnaire was used to evaluate the quality of the model and user satisfaction. Results: The developed wound models were made from silicone. The quality evaluation form determined that the developed models had higher overall quality than those previous models available in nursing laboratory center. User satisfaction with the developed models was high. The overall mean (SD) of user satisfaction toward the developed closed-wound model and open-wound model were 3.41 (0.72) and 3.44 (0.71), respectively. Conclusions: The developed wound models are potentially useful and user friendly, and could be easily available in settings of education with limited resources. Encouraging the students to use these models may help to enhance self-directed learning and clinical skills for application of wound dressings.

Analyze the effectiveness of mandated point-of-care (POC) blood glucose (BG) meter quality control (QC) testing. All POC BG QC tests were analyzed to evaluate operator and strip/meter error rates and institutional cost. POC BG QC test failure (17/103,580 over 24 months) was low and no meters failed subsequent linearity testing. Examining individual QC measures shows that operator error occurs frequently and total error rate is related to QC familiarity (>50 QC tests/month, 2.4%

Background Hospital-acquired pressure ulcers are a common problem. Although a number of risk factors have been identified, relationships among risk profile characteristics and pressure ulcer outcomes have not been described in hospitalized patients. Objectives To describe patients' characteristics and risk factors associated with pressure ulcer outcome. Methods A retrospective chart review was used to collect data on 87 patients in whom hospital-acquired pressure ulcers developed from May 2007 to November 2008. All pressure ulcers were staged by a certified wound nurse. Relationships among risk profile characteristics and pressure ulcer outcomes were determined via bivariate analysis and multivariate logistic regression. Results High severity of illness was present in patients with hospital-acquired pressure ulcers; 89% were intensive care patients. Vasopressor infusion, spinal cord injury, and age 40 or greater conferred risk for nonhealing pressure ulcers. Among pressure ulcer stages, suspected deep tissue injury ulcers were less likely to heal. Conclusions Identification of characteristics and risk factors associated with development of nonhealing hospital-acquired pressure ulcers will allow nurses to recognize patients at risk for nonhealing and to take aggressive preventative measures.

Hospital-acquired pressure ulcers (HAPUs) are a national concern due to patient morbidity, treatment cost, and reimbursement issues. Stages III and IV pressure ulcers (PUs) that occur during hospitalization are among the conditions considered preventable by the Centers for Medicare and Medicaid Services (CMS). Harborview Medical Center (HMC), located in Seattle, WA, is a Level 1 trauma/burn center and safety net hospital serving diverse populations. HMC is committed to providing excellence in care including optimal skin care and PU prevention to people from all walks of life. At HMC a new system for monitoring daily PU incidence, completing monthly multidisciplinary intensive reviews on HAPUs, and application of an algorithm used to determine if HAPUs were avoidable was developed and implemented. This system has assisted HMC in addressing PU tracking, prevention, compliance with regulatory mandates and has improved skin-related outcomes.

In wound healing studies that investigate therapeutic interventions, it is important to characterize cellular responses. In a randomized trial enrolling patients at risk for surgical infection, one goal is to phenotype cells within a polytetrafluoroethylene implant using flow cytometry and immunohistochemistry, together with standard hematoxylin- and eosin-based histology. Subcutaneous implants are removed 8-9 days postoperatively. To obtain single cells associated with the mechanism of wound healing, we initially used a mouse skin digestion protocol. We optimized this to increase the cell yield and isolate sufficient cells for flow cytometry. The modifications increased the total cells recovered per subject from an average of 5.3 x 10(4)-41 x 10(4) with an average viability of 80%. The immunoflourescent staining assay was verified for our samples, which have smaller cell sample numbers than tissue biopsies. Thirty-two samples were stained. Cells from the polytetrafluoroethylene tubes were isolated and stained positively with fluorescent-labeled antibodies to CD3, CD20, CD31, CD34, CD68, CD133, and VEGF receptor type 2. Flow cytometry data correlated with immunohistochemistry data especially with respect to CD68. This antigen was the most prevalent in both the cell analysis methods. Our findings demonstrate that flow cytometry can be used with polytetrafluoroethylene samples as an additional evaluation method to document and describe cellular wound healing responses.

Background The purposes of this study were to (1) describe physical activity of adult manual wheelchair users as measured by wrist actigraphy and two self-report measures, (2) compare exercisers and nonexercisers on measures of physical activity, and (3) examine the relationships between three activity measures. Methods Fifty manual wheelchair users wore an activity monitor and completed a physical activity record for 7 days. At the completion of this period, a questionnaire that included the Physical Activity Scale for Individuals with Physical Disabilities, stage of exercise question, and demographic and health questions was completed. Results Mean daily hours spent in bed or asleep was 9.1, mean hours of light intensity activity was 12.5, mean hours of moderate intensity activity was 1.3, and mean hours of strenuous activity was 0.33. Thirty-eight percent did not report any strenuous activity, and 56% reported less than the 150 minutes weekly of moderate or strenuous activity required to meet public health guidelines. There was variability in both self-reported and objectively measured physical activity. Regular exercisers were not significantly different from nonexercisers on objective measures of physical activity. Measured physical movement was weakly correlated with recall of physical activity or exercise. Conclusion Many wheelchair users do not meet public health guidelines for physical activity, but they are not a homogeneous group in intensity and frequency of physical activity. Multiple measurement methods can provide insights into the nature, intensity, and duration of physical activity that is more complex due to variations in abilities and ways of moving.

The Wound Healing Society is a professional organization of physicians, nurses, physical therapists, basic scientists, clinical researchers, and industrial researchers dedicated to assuring that every patient receives optimal wound care. Its mission is to advance the science and practice of wound healing. To that end, the following comprehensive, evidence- and consensus-based guidelines were developed to address the Prevention of Pressure Ulcers. The guidelines are presented in generic terms; the details of specific tests, therapies, and procedures are the discretion of an interdisciplinary team of health care professionals who establish, implement, and evaluate policies and procedures directed at the prevention of pressure ulcers.

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.

The University of Washington Doctor of Nursing Practice program entails 3 curricular dimensions: advanced practice, leadership, and practice inquiry. In this article, the practice inquiry dimension is discussed and defined as a type of clinical investigation that closely aligns with the realities and complexities of everyday practice by advanced practice nurses (APNs). The advancement of APNs' practice inquiry competencies is timely for its interfaces with the national scientific agenda's emphasis on translating science to clinical practice, health care delivery systems and policy. A framework for conceptualizing a practice inquiry curriculum and competencies is proposed. In addition, the divergent and convergent comparisons with Doctor of Philosophy (PhD) nursing programs are discussed, with emphasis placed on potential collaborative clinical research endeavors.

This article discusses the current literature related to intraoperative and preoperative risk factors for pressure ulcer development. Although surgical patients have a high risk of pressure ulcer development, the intraoperative period of patient care has often been missed as a time of increased risk. Pressure ulcers, which may originate in the operating room, may be incorrectly blamed on postoperative areas of care resulting from delay of pressure ulcer demarcation. In the literature review, current risk assessment tools do not adequately address intraoperative risk factors. A risk assessment tool that incorporates the specific variables relevant to the preoperative and intraoperative environment is proposed based on existing literature. A pilot study of the tool was done testing for intrarater reliability.

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.

Numerous reports support the concept that tissues require an adequate oxygen supply to heal well and to prevent complications of infection. Adequate oxygen supply to tissue depends on perfusion as well as arterial oxygen tension, and tissue oxygen tension, particularly in peripheral tissues, is dependent on adequate vascular volume. Therefore, potential benefits to wound healing and reduction in infection in postsurgical patients might be attained by judicious manipulation of supplemental oxygen and/or fluids in the perioperative period. This article reviews evidence that suggests such manipulations are beneficial and proposes that integrated care pathways be developed that include these interventions.

• 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.

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°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°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. (J WOCN 2001;28:244-52.)

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.

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.

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.

The purpose of this study was to examine effects of sleep deprivation on cellular and biochemical markers of wound healing. Expanded polytetrafluoroethylene tubing inserted in subcutaneous tissue created miniature wounds in the dorsal skin of 12 rats. Seven days later, 6 rats were deprived of sleep by the platform method for 72 hr; control rats remained on usual sleep/wake routines. Numbers of macrophages, granulocytes, fibroblasts, and extent of connective tissue present and total amounts of protein, DNA, and hydroxyproline in the implants were not different between sleep-deprived and control rats. There is no evidence from this study that sleep deprivation impairs cellular and biochemical indicators of tissue repair.

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.

Hospital-acquired pressure ulcers (HAPU) are a growing concern in patient care. Mucosal pressure ulcers (PUs) on the lips, mouth, gums, and tongue caused by oral intubation and their securement devices can be difficult to identify and prevent. In an effort to address this problem and reduce mucosal PU, implementation of an alternative securement device, the Hollister ETAD endotracheal (ET) tube securing device, in conjunction with the B&B Medical Universal Bite Block, was introduced at our institution, a level 1 trauma and burn center, in July 2007. The ETAD was later replaced by the Hollister AnchorFast ET tube securing device in December 2007. By April 2009, they became the standard devices and method used to secure oral ET tubes. We hypothesized the use of the new securement devices and bite block would lead to a decrease of HAPUs on the lips, mouth, gums, and tongue of orally intubated critical care patients because these allow for better oral assessment and ET tube manipulation to redistribute pressure. Using data collected from our electronic medical record and our HAPU incidence tracking system, we analyzed the number of PUs on the lips, mouth, gums, and tongue of orally intubated patients in our preintervention (phase 1) group compared with the data from our postintervention (phases 2 and 3) groups. A clinically significant decrease in the reported incidence of HAPUs on the lips, mouth, gums, and tongue was noted in our phases 2 and 3 groups following introduction of the ETAD, AnchorFast, and Universal Bite Block in our institution.

Background and Purpose. Microamperage direct current and microamperage electromagnetic stimulation are used to accelerate healing in bone. Although many clinicians are using microamperage stimulation to relieve pain and facilitate wound healing, there is significant question regarding whether this low-intensity direct current significantly accelerates soft tissue wound repair. The purpose of this study was to determine whether low-voltage pulsed microamperage current (100 μA, 60 V, 0.1 Hz) enhances the healing of superficial, full-thickness, or incisional wounds created to simulate acute abrasions, ulcers, and lacerations. Subjects. Ten adult Yucatan mini pigs served as the subjects for this study. Methods. Variables associated with healing were measured in 60 matched pairs of surgically induced partial-thickness, full-thickness, and incisional wounds after either sham or anodal (positive-polarity) stimulation with pulsed microamperage current (100 μA) was administered for 1 hour per day for 5 days. Sterile, disposable electrodes (2×4 cm) were placed over each wound, which was kept wrapped and protected throughout the study. Results. At 7 days postinjury, all wounds were healing well with no signs of infection. There were no differences in tensile strength, collagen density, maturity, or deposition (hydroxyproline), wound size, or visual appearance between the sham treatment and treatment lesions. No changes in local subcutaneous oxygen or temperature were found in the swine during or after microamperage stimulation. Conclusion and Discussion. This study did not provide any evidence to support the use of microamperage stimulation to accelerate wound healing. No negative effects, however, were found. Further research is needed to determine whether there is a critical interaction between the size of the electrode relative to the wound, the density of the current, the duration of the treatment, the polarity of the treatment electrode, and the acuity or chronicity of wounding and the effectiveness of microcurrent stimulation for wound healing.

Although difficult to quantify due to methodological variations, the worldwide burden of pressure ulcers (PUs) is substantial. Recognizing the importance of providing evidence-based care to help reduce this burden, the North American Wound Care Council societies collaborated to identify PU research and education opportunities using the PU "Guideline of Guidelines" developed and tested by Association for the Advancement of Wound Care Guideline Department (AAWC GD). Volunteer AAWC GD members compiled recommendations from PU guidelines available in 2008, searched the lit- erature for additional research as needed, and developed evidence levels for all recommendations using an established level-of-evidence rating scheme. At the same time, AAWC members and Ostomy Wound Management readers were invited via email to participate in a content validation study of the 368 recommendations, rating items on a scale of 1 (not relevant) to 4 (very relevant and succinct). Items with a content validity index (CVI)0.75 were considered valid. Recommendations with support from two or more randomized controlled PU trials or two or more cohort studies for diagnostic or predictive validity (A-level evidence) and a CVI75 were grouped as ready for implementation. Recommendations with content validity but without A-level evidence were determined to be opportunities for research; recommendations that lacked content validity but that had A-level evidence were viewed as opportunities for education. Thirty-two (32) multidisciplinary healthcare professionals participated in the content validation study. Most (93.2%) recommendations were rated as valid. Of the 97 (26%) recommendations with A-level evidence, 90 (24.5% of total) met both strong content validity and strong evidence criteria and were rated as ready for implementation as standard of care. Most recommendations (253, 68.8%) were rated as valid but had B- or C-level evidence, representing opportunities for research. Only seven (1.9%) recommendations had a low CVI but A-level evidence, suggesting a need for education. The results show that most of the guideline recommendations are valid, that the number of PU intervention recommendations with A-level evidence is increasing, but that, in general, the need for research to replace opinion with evidence remains high across the entire spectrum of PU prevention and treatment. Understanding what is known (recommendation: ready to implement), what is not known (research needed), and what clinicians need to know (education needed) is an important step toward reducing the burden of pressure ulcers. difficile are warranted.

In a 14-week medical-surgical nursing review course, two teaching strategies are used to promote active learning and assess the transfer of knowledge to nursing practice. Practice tests and clinical examples provide opportunities for participants to engage in self-assessment and reflective learning and enhance their nursing knowledge, skills, and practice. These strategies also contribute to program evaluation and are adaptable to a variety of course formats, including traditional classroom, web conference, and online self-study.

In wound healing studies that investigate therapeutic interventions, it is important to characterize cellular responses. In a randomized trial enrolling patients at risk for surgical infection, one goal is to phenotype cells within a polytetrafluoroethylene implant using flow cytometry and immunohistochemistry, together with standard hematoxylin- and eosin-based histology. Subcutaneous implants are removed 8-9 days postoperatively. To obtain single cells associated with the mechanism of wound healing, we initially used a mouse skin digestion protocol. We optimized this to increase the cell yield and isolate sufficient cells for flow cytometry. The modifications increased the total cells recovered per subject from an average of 5.3 x 10(4)-41 x 10(4) with an average viability of 80%. The immunoflourescent staining assay was verified for our samples, which have smaller cell sample numbers than tissue biopsies. Thirty-two samples were stained. Cells from the polytetrafluoroethylene tubes were isolated and stained positively with fluorescent-labeled antibodies to CD3, CD20, CD31, CD34, CD68, CD133, and VEGF receptor type 2. Flow cytometry data correlated with immunohistochemistry data especially with respect to CD68. This antigen was the most prevalent in both the cell analysis methods. Our findings demonstrate that flow cytometry can be used with polytetrafluoroethylene samples as an additional evaluation method to document and describe cellular wound healing responses.