SAWC Fall 2018 Poster Abstracts

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When the Symposium on Advanced Wound Care (SAWC) Fall sets up shop at Caesars Palace in Las Vegas, Nevada, November 2–4, 2018, attendees will need to judiciously divide their time among the many sessions and events. Make sure to include the Poster Hall (Saturday, November 3, 8:00 a.m.–4:00 p.m.), the Poster Reception (Saturday, November 3, 5:30 p.m.–6:15 p.m.), and the Oral Abstract session (Sunday, November 4, 11:20 a.m.–12:20 p.m.). Here are the top-scoring abstracts you will want to learn more about.

Information/Educational Report
An Innovative Literacy-supportive Education Pilot for Wound Self-care

Erin Tharalson, DNP, RN, ANP-BC, CWS; and Lynda Root, DNP, RN, PMHCNS-BC

As the incidence of acute and chronic wound conditions rises and wound dressing protocols become more complex, uninsured patients lacking access to specialty wound care are challenged to manage their own wounds. Understanding of multistep dressing change protocols may be inhibited by low health literacy. Low health literacy is associated with reduced disease knowledge and self-care. Little evidence of the effects of health literacy on wound patients or information on literacy-sensitive educational interventions that address wound knowledge and self-care is available. Improved outcomes occur in all health literacy levels in other diseases with the use of literacy-sensitive educational interventions that incorporate more than one literacy strategy over multiple sessions. To examine the effectiveness of a literacy-sensitive wound education intervention on wound knowledge and self-care, an evidence-based pilot project was conducted in an urban wound clinic. A convenience sample of 21 patients received a literacy-sensitive wound education intervention consisting of spoken and written communication over several sessions. Instruments measured health literacy level, wound knowledge, dressing performance, and wound healing status. There was a significant increase in wound knowledge scores in all literacy groups from baseline to visit 2 (P <.01) and 4 (P <.01). Dressing performance scores remained consistently high through visit 4 in all literacy levels. All participants’ wounds progressed toward wound healing significantly from baseline to visit 2 (P <.01) and 4 (P <.01). Incorporation of a literacy-sensitive education intervention with supportive literacy aids over several sessions supports improved wound knowledge and dressing self-care and can affect healing in patients of all health literacy levels.

Clinical Research
Use of a Patient Mobility Monitoring System to Reduce Pressure Injuries in the Critical Care Population
Dana Nichols, RN, CCRN 

To address a high rate of hospital-acquired pressure injuries (HAPIs) in intensive care units (ICUs), a wireless, wearable patient mobility monitoring system (PMMS) was implemented in addition to standard pressure injury prevention practices for patients with an expected ICU stay >48 hours, intubation >12 hours, and/or a Braden Scale score <12 with low subscale scores in 2 or more categories. By monitoring the degree to which each patient was turned, as well as duration of time on each site, the PMMS provided real-time visible information and cues. The staff was educated on these visual cues and thus prompted adequate turning according to the individual patient protocol. It was discovered that staff typically turned patients in a timely manner, but the degree to which they turned patients was not always enough to offload the pressure areas. The PMMS was able to provide information and cues to ensure that patients were turned both timely and adequately. 

During the initial 18 months of the study, 1419 patients were monitored. With the use of the PMMS to cue on-time, good quality turning, HAPIs were reduced from 24 to 10, a 58% reduction. Based upon the cost to treat 24 pressure injuries, the reduction in HAPIs, and the cost of the PMMS system, the hospital saved $315,311 during the first 18 months.

With continued use of the PMMS, daily and monthly reports on turning compliance are provided. From the information provided, HAPIs and associated costs have decreased, teamwork has improved, and a turn compliance of >90% has been maintained.

Clinical Research
Dressing Neonatal PIVs: A Quality Improvement Project to Reduce Neonatal Extravasations in a Level 4 NICU
Colleen Galiczewski, NNP; and Vitaliya Boyar, MD

A peripheral IV (PIV) is placed in 60% to 70% of infants in the NICU. Extravasation injuries occur in 18% to 33%, 70% of them in extremely preterm babies <27 weeks of gestational age. Despite such frequent use of PIV therapy, evidence on best practice, IV maintenance, injury prevention, and management in neonates is scarce. Clinicians must deal with increased incidence and severity of neonatal extravasations; inconsistencies in nursing placement, securement, and assessment of PIVs; and extravasation staging and management. Baseline extravasation data were obtained retrospectively from the hospital’s electronic database for 6 months prior to this quality improvement (QI) initiative. The principal QI intervention included the development and implementation of dressing protocol for PIV securement and a guidance algorithm for the evaluation, staging, and management of  extravasations, with emphasis on uniform securement, frequent evaluation and documentation, and consistent management.

This QI initiative was implemented through multiple Plan-Do-Study-Act cycles, starting in July 2017 (education phase). Data were collected prospectively (Implementation/Maintenance phases) until May 2018. The objective was to achieve a 20% reduction in extravasation prevalence and a 40% decrease in severity (stage 3/4) in all newborns admitted to the NICU regardless of gestation age.

The overall prevalence decreased by 40% over the preceding year. At baseline, 53% were severe (Stage 3/4) extravasations. Severe extravasations decreased by 30% (and are currently 19%). The overall rate of adherence to the PIV evaluation/management algorithm was close to 90% to 95%, whereas adherence to securement guideline fluctuated between 80% and 98%, indicating the need for frequent reminders and reinforcement and implying that nursing practices and culture are integral to the process but difficult to change.

The implementation of these new practices along with this education has resulted in a decreased rate and severity of extravasation with overall improvement in patient outcomes. Random audits and continuous staff involvement ensures accountability.

Clinical Research
The LeucoPatch System in the Management of Hard-to-heal Diabetic Foot Ulcers of More Than 12 Months’ Duration: A Subgroup Analysis of a Multicenter, Multinational, Observer-blinded, Randomized Controlled Trial
Magnus Löndahl, William Jeffcoate, Lisa Tarnow, Judith Jacobsen, and Frances Game

The LeucoPatch device uses bedside centrifugation without additional reagents to generate a disc comprising autologous platelet-rich fibrin and leucocytes that is applied to the surface of the wound. In a randomized multicenter trial in which 595 people with diabetes and a diabetic foot ulcer consented to participate, after a 4-week run-in period, persons with a reduction in ulcer area of <50% were randomized to either prespecified good standard care alone (control) or care supplemented by weekly application of the LeucoPatch. In the intervention group, 45/132 ulcers (34.1%) healed within 20 weeks versus 29/134 (21.6%) of the controls (OR 1.58; 95% CI 1.06- .35; P = .02) by intention-to-treat analysis. The aim of this subgroup analysis was to evaluate the effect of LeucoPatch in those with hard-to-heal ulcers with a duration of 12 months or more.

A subgroup analysis of the LeucoPatch II study population was conducted with the primary outcome the percentage of ulcers healed within 20 weeks. Healing was defined as complete epithelialization (confirmed by an observer blind to randomization group) maintained for 4 weeks. 

Randomized participants included 292 people with an ulcer duration of 12 months or more. In the intervention group 11/44 ulcers (25.0%) healed within 20 weeks versus 3/48 (6.2%) of the controls (OR 4.31; 95% CI 1.20-15.4; P = .019) by intention-to-treat analysis. Time to healing was shorter in the intervention group (P = .013). No difference in adverse events was seen between groups.

The use of LeucoPatch is associated with significant enhancement of healing in hard-to heal foot ulcers with a duration of 12 months or more in people with diabetes.

Informational/Educational Report
Skin and Wound Map from 23 453 Nursing Home Resident Records
Yunghan Au, PhD, MBA; Marc Laforet, MSc; and Sheila C. Wang, MD, PhD

The overall distribution of skin and wound problems experienced by residents in nursing homes related to the location on the body is poorly understood. Previous studies generally only focus on one disease state, rather than all possible skin lesions. Hence, the relative distribution of these conditions as mapped on the body has not previously been reported. In addition, existing data are mainly confined to clinical studies and voluntarily reported statistics; hence, real-world data in this care setting are scarce.

In order to understand the type and location of skin and wound lesions found in long-term post-acute care (LTPAC) facilities and map these on the body, data from 23 453 skin and wound lesions, as collected through the Minimal Data Set submissions collected using a smartphone application, were used to generate heat maps to identify the most common areas of skin and wound lesions. These data also were used to identify the most common wound types at different body locations. 

The most common wound types were abrasion (37.5%), followed by pressure ulcers (17.4%), surgical wounds (13.2%), and skin tears (9.4%). The most common skin and wound locations were the coccyx (4.1%), left (3.6%) and right (3.6%) forearms, and sacrum (3.5%).

This study represents an example of how analysis of specialized electronic medical records can be used to generate insights in order to educate and inform facility managers where to focus their efforts to prevent these injuries from occurring, not only from retrospective database analysis, but also in near real-time. We have presented location hotspots of skin and wound lesions experienced by LTPAC residents. We believe that elucidating body locations prone to preventable wounds can direct actions taken by care workers and improve the quality of care for nursing home residents.

Information/Educational Report
Revolutionizing Wound Documentation Starting at the Bedside
Sharon W. George, BSN, RN, WCC; Marivel Segura, BSN, RN, WCC, CCRN; and Tammy L. Regitz RN, WCC, Alumnus CCRN 

Accurate and consistent wound documentation is a continuous struggle for the bedside nurse. One of challenges that arose in our 800-bed facility was getting all nurses to properly assess and document all noted wounds. Another challenge was to eliminate paper documentation, especially within our burn unit. As a pressure ulcer prevention team, the goal was to find ways to help expedite solutions for bedside nurses.

Paper documentation was the standard from the beginning of time. In 2011, we transitioned wound documentation to an electronic medical record (EMR) by adding a wound flowsheet that would allow nurses to add wound characteristics. During this 2-year process, we found multiple issues. One was that nurses would document incorrect anatomical locations as well as neglect to input full wound descriptions on the flowsheet. These inconsistencies urged us to formulate a new process that would close the gaps and allow continuity of care from nurse to nurse. For our new process, we used a multinursing specialty collaboration team that resulted in the creation of an electronic wound man, known as “Wound NoteWriter.” Buttons were built so nurses could choose from standard wound characteristics and treatment. This allowed the nurse to document on the exact anatomical location using standardized descriptors and treatment plans. 

When Wound NoteWriter was implemented, we saw an increase in compliance, with nurses documenting on wounds and implementing treatment plans. We also noted nurses found their documentation more visually pleasing and allowed them to tell a complete story with regard to wound development. This new process facilitated engagement in wound documentation. 

Inconsistencies and unstandardized methods in documentation can limit your potential growth in your facility. Consider using a multidisciplinary approach, including leadership, management, and bedside nurses, to create a standardize process that improves work flow and supports the facility.

Information/Educational Report
Standardizing Tracheostomy Care
Marivel Segura, BSN, RN, WCC, CCRN; Sharon W. George BSN, RN, WCC; and Tammy L. Regitz RN, WCC, Alumnus CCRN

Standardizing tracheostomy suture removal always has been a challenge in the medical field. Our safety net facility, with approximately 900 beds, has treated 4 patients with full-thickness pressure injuries thus far. This is an alarming increase from last year, because these all were found within a 4-month period. Upon investigation, our common gap was leaving sutures in beyond the recommended time frame of 5 to 7 days postoperatively. It also was recognized that there was no standardized documentation for physicians and nurses. 

A multidisciplinary approach was utilized to create solutions that involved team collaboration, prompt interventions, and standardized documentation. The wound care team immediately approached the Care Assessment Trach Team (expert otolaryngologist and speech and respiratory therapists) regarding the concern of pressure injuries under the tracheostomy devices. From this notification, communication among providers directly lead to awareness in their practice and assisted in resolving the issue. Wound care continued to work with bedside nurses, leadership, and safety risk managers to create a new documentation process for suture removal date. Meanwhile, the providers remained connected and worked together to standardize the tracheostomy postoperative order set for all surgical services. 

This process allowed formal documentation by having a place for nurses to record the suture removal date. If sutures are not removed per guidelines, providers must be notified and the reason for no intervention should be documented. This holds nurses and providers accountable for timely suture removal. Physicians now have a uniform process to order “tracheostomy postoperative care” via an order set. This allows consistency among all surgical services. No new injuries have been reported. 

Having a multidisciplinary team that supports standards of care per expert recommendations can be lifesaving to a patient and facility. A regulated process ensures early interventions to avoid permanent damage to the patient.

Clinical Research
Pressure Ulcer-related Health Care Costs of Patients in the United States From a Commercially Managed Payer’s Perspective
Ankur Patel, MS, BPharm; and Gary Delhougne JD, MHA, BA

Pressure ulcers (PUs) pose substantial clinical and economic challenges to patients and health care providers, annually affecting an estimated 2.5 million patients in the United States (US) at a substantial cost estimated to range from $9.1 to $11.6 billion annually. Recent research states Medicare pays between $3696 and $21 060 per patient; however, limited data from commercial payers exist. The objective of this study was to estimate PU-related health care costs in the US from a commercially managed US payer perspective.

Humana databases contained within the PearlDiver were retrospectively reviewed to identify PU patients using ICD9-CM and ICD10-CM codes between 2013 and 2015. The year of first PU diagnosis, age group, gender, race, and US region were recorded for PU patients. PU-related health care costs were estimated in 3-, 6-, 9-, and 12-month follow-up periods of continuously enrolled patients. We also reported PU-related health care costs by site and stage of PU.

There were 102 783 PU patients (53% female, 67% white, 64% south region, 71% >70 years of age) identified between 2013 and 2015. PU-related health care costs were reported for patients who were continuously enrolled for 3 months ($11 731), 6 months ($12 047), 9 months ($12 392) and 12 months ($12 836) in year 2013. Similarly, PU-related health care costs were between $11 033 and $13 595 in 2014 and 2015. PU-related health care costs were between $8656 and $9826 for Stage 3 patients and between $19 972 and $23 852 for Stage 4 patients. PU-related health care costs were highest ($12 532 to $14 592) for sacral PUs and lowest ($969 to $1128) for patients with a PU coded as an unspecified site.

PU patients inflict a significant cost burden on the US health care system and effective prevention, treatments, and products may help payers reduce the economic burden and clinical outcomes in PU patients.

Clinical Research
A Single-site Randomized Clinical Trial Comparing the Concomitant Use of Two Urinary Bladder Matrix Devices to Standard of Care in Patients With Stage 3 or 4 Pressure Injuries: An Interim Analysis
Carol P. Bowen-Wells, MD

Management of pressure injuries (PI) with urinary bladder matrix (UBM) devices, with and without negative wound pressure therapy (NPWT), was evaluated. It was hypothesized that the mean rate of healing will be superior with UBM alone compared to NPWT alone. Secondarily, it was hypothesized that the rate of healing with UBM+NPWT will be superior to NPWT alone.

Patients meeting inclusion/exclusion criteria were being enrolled and randomized (1:1:1) to Group 1 (UBM), 2 (UBM+NPWT), or 3 (NPWT). Group 1 received treatment of UBM; Group 2 received treatment of UBM+NPWT; Group 3 received NPWT. NPWT was applied following manufacturer’s instructions for use. Follow-up was weekly through 12 weeks post-surgery, then at 26 weeks with offloading prescribed whenever possible.

Of the 45 persons who consented to participate, to date 35 were enrolled. Data were presented as Group 1/2/3. Enrollment was 12/11/12 participants, respectively, with number of treated wounds of 15/12/13, respectively No differences were observed for baseline characteristics, including age at consent: 58.9 ± 17.2/63.7±19.9/69.2±15.0, respectively; gender (M:F): 8:4/8:3/6:6, respectively; wheelchair bound: 7/4/3, respectively; and average body mass index (BMI): 25.98±5.01/25.38±8.90/22.54±8.90, respectively. Ratio of Stage 3:Stage 4 PIs post-debridement was 1:14/1:10 (1 unk)/3:8 (2 unk), respectively. Mean wound area (cm2) at randomization was 22.89±19.24/31.98±20.25/19.37±14.14, respectively.

The mean rate of wound healing, cm2/week by wound, was -0.023±0.022/-0.017±0.031/0.0003±0.0343, respectively. Of the 24 participants with 28 wounds who completed the 12-week follow-up visit at interim analysis, complete wound closure was seen in 1/0/0 wounds, respectively. In addition, 16 participants with 20 wounds completed the 26-week follow-up. Complete wound healing was seen in 4/0/2 wounds, respectively. No device or procedure-related adverse events were observed. Periwound maceration was reported for 3/8/10 participants, respectively. Statistical analysis will be completed with larger sample accrual.

Management of PIs with UBM is trending to show superiority over management with NPWT. This finding is consistent when UBM is used in combination with NPWT as compared to NPWT alone.

Indformation/Educational Report
Cost-effectiveness of the Use of a Multilayer Polyurethane Foam Dressing for the Prevention of Pressure Ulcers in Elderly Patients with Hip Fractures
Richard Searle and Cristiana Forni

Hospital-acquired pressure ulcers (PU) continue to impose a cost burden on hospital providers, primarily driven by the resources used to treat complications. These additional resources may include extended hospital stay. Strategies to prevent PU are therefore an important consideration for hospitals. A recently published randomized controlled trial (RCT) reported the use of a multilayer, silicone-adhesive polyurethane foam dressing along with standard preventive care was effective in reducing the incidence of PU. It is of further interest to determine whether the intervention is likely to be more cost-effective than standard prevention alone.

A model was constructed to determine the cost effectiveness of the foam dressing strategy along with standard prevention compared with standard prevention alone. PU incidence data from the recent RCT were used.

The foam dressing intervention was found to be cost saving and more effective than standard preventive care. Switching to the foam dressing along with standard prevention would result in an expected cost saving of $839 per patient and an expected reduction of 0.109 PUs per patient.

This analysis suggests that in elderly frail patients, the use of a multilayer, silicone-adhesive polyurethane foam dressing combined with standard preventive care is more cost effective than standard care alone. The strategy is expected to be both cost-saving and more effective than standard preventive care.

Case Series/Study
Shifting Focus: Implications of Periwound Bacterial Load on Wound Hygiene
Rosemary Hill, BSN, CWOCN, WOCC(c); and Joshua  Douglas,  MD, FRCPC, ABIM

Wound cleansing is the most ubiquitous method used to maintain optimal wound hygiene because it is available at all clinical settings and skill levels. The periwound is often a neglected area but serves as a source for microbial recontamination if not adequately cleansed. Fluorescence imaging has been used to visualize red-fluorescing, pathogenic bacteria in the wound bed and periwound area at the bedside using a noncontact, handheld device. The visualization of bacterial load can be incorporated to optimize wound hygiene by guiding targeted cleansing and debridement. Recently available improved skin and wound cleansing agents with lower concentrations of sodium hypochlorite, which are purported to disrupt biofilm and kill planktonic bacteria while still safe for the wound bed, may optimize wound hygiene. Effectiveness of such cleansers compared to standard practice is reported here.

In a series of 10 patients, bioburden reduction was assessed by fluorescence imaging and visualization of bacterial load.  The wound bed and periwound area were cleansed using saline or 0.057% sodium hypochlorite.  

Of the 10 patient participants, 9 had bacterial load present outside of the wound bed. Periwound/wound cleansing with traditional saline was not sufficient to remove bacterial load from 9/10 patients.  Low-concentration sodium hypochlorite was effective at eradicating the bioburden from 6/9 patients; however 3/9 patients required debridement to fully eliminate the bioburden.  

Timely management of wound bioburden is imperative to support overall healing. Wound hygiene is possible only if the location of bioburden is identified in the wound/periwound area and removed with effective cleansing agents.