Total Contact Cast Guidelines

October 28, 2011 — Matthew Livingston R.N. C.W.S.

Intended use of Total Contact Casts

Total Contact Casts are typically intended for diabetic planter ulcers.Total Contact Cast

Hold or don’t initiate a Total Contact Cast if:

1. Infection
2. Critical limb ischemia Tcom < 30mmHg
3. Major illness / Unstable patient
4. Frail / Bad hip or back
5. Non-compliance (overactive)

Quick Fixes for Total Contact Cast Complications:

1. Heavy Drainage – Biweekly changes
2. Toe Drainage – Open toe cast
3. Discomfort – Add padding
4. Chafed skin -  Add padding
5. Pre-ulcerated lesion on pressure point – offload pressure point
6. New ulcer – offload pressure point

Consider a DH Walker if you are unable to control for:     DH Walker

1. Discomfort with extra padding
2. Chafed skin with extra padding
3. New ulcer formation continues regardless of offloading
4. Lower extremity joint problems

Note: DH Walkers are hard to ambulate in for patients with a weak gait. If this is the case consider a walker. If it is still difficult for the patient to ambulate consider a wedge shoe (Darco).

Note: Consider a Crow Boot for patients who have a rocker bottom (Charcot) foot deformity.

Posted in Diabetic Wounds. Tags: , , , , , . Leave a Comment »

Diabetic Wound Best Practice Evidence

October 6, 2011 — Matthew Livingston R.N. C.W.S.

Diabetic Etiology Wound Evidence Based Research

Diabetic Etiology 20 week of healing benchmark

Research indicates that 67% of diabetic foot ulcers remain unhealed after 20 weeks of care. (Note: Average healed at 20 weeks is 33%)

Kantor J, Margolis DJ. Expected healing rates for chronic wounds. WOUNDS. 2000;12(6):155-158

RESULTS—Wound area measurements at baseline and after 4 weeks were performed in 203 patients. The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed versus those not healed at 12 weeks was found to be 53%. Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01). The absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers (1.5 vs. 0.8 cm2, P < 0.02). The percent change in wound area at 4 weeks in those who healed was 82% (95% CI 70–94), whereas in those who failed to heal, the percent change in wound area was 25% (15–35; P < 0.001).

Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial Peter Sheehan, MD1,Peter Jones, MSC2,Antonella Caselli, MD3 John M. Giurini, DPM3 and Aristidis Veves, MD3

10.2337/diacare.26.6.1879 Diabetes Care June 2003 vol. 26 no. 6 1879-1882

Nutrition

“Basic principles of nutritional management of a patient with diabetes mellitus to control glucose, hyperlipidemia, and hypertension should be applied to the patient who has developed neuropathic foot ulcers.”

Level of Evidence=C

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 24

Offloading

“Ensure adequate offloading of pressure through wound closure. Utilize assistive devices to provide support, balance, and offloading of the affected site.”

Recommendation

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 17

TCOM

A transcutaneous oxygen monitor study “is indicated to assess tissue perfusion when the lower extremity wound is not healing or an ABI or toe pressures can not be done due to incompressible arteries” (Grolman et.al. 2001: Hopf et al., 2006: Stalc & Poderos, 2002).

Level of Evidence = A

WOCNS, 2008. Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease. Pg. 14

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy  “has been demonstrated to be effective for the treatment of neuropathic/diabetic ulcers and skin graft and donor sites.”

Level of Evidence = B

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27

Skin Substitutes

Skin Substitutes have the potential to stimulate, through topical activation the normal or enhanced activity of mechanisms involved in tissue repair.

(Gentzkow, Iwasaki, Hershon, Mengel, Prendergast, Ricotta et al., 1996; Gentzkow, Jensen, Pollak, Kroeker, Lerner, Lerner et al., 1999; Marston, Hanft, Norwood & Pollak, 2003)

Level of Evidence = 1b

Hyperbaric

“Hyperbaric oxygen therapy may be clinically effective in treating patients with limb-threatening diabetic wounds of the lower extremity (Wagner grades III and IV)

Level of Evidence = A

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27

Posted in Diabetic Wounds. Tags: , , , , . 1 Comment »

Five Ways to Build the Ideal Wound Clinic

October 3, 2011 — Matthew Livingston R.N. C.W.S.

Five ways to build the ideal wound clinic

1. Build a large referral base

A. Become an expert in wound care and hyperbarics (do research and publish)

B. Get in front of as many doctors as possible and share what you know. Become well connected in the hospital and the hospitals system.

C. Let them know that you are an adjunct to their care and that you will be working to keep them informed of patient progress.

D. Maintain active communications with the referring physicians.

2. Recruit all types of specialists to work as wound physicians.

A. This includes Vascular, General Surgery, Trauma, Plastics. ID, Internal Med, Podiatry. etc…

B. Make sure that there are open cross referral patterns between these doctors.

C. With this in mind, recruit doctors that have an us (not me) mentality as sharing referrals can improve patient outcome and better outcomes means more referrals.

3. Provide Advanced Wound Care

A. Have physicians who can manage complex wound etiologies such as micro-occlusive and autoimmune disorders.

B. Insure that you have physicians available who can provide surgical interventions such as complex flaps.

4. Provide a process driven wound care environment

A. Benchmark wound healing outcomes by etiology, with goals for how to improve lower preforming healing outcomes.

B. Create evidence based protocols for the care of your patients.

C. Foster staff / clinician / physician  process improvement committees which drive improvements such as clinic development, patient safety, and new product review.

5. Create accurate and seamless documentation

A. Invest in a wound care related electronic medical record (EMR).

B. Insure that the EMR company has on the ground training that not only trains towards the EMR, but also how the EMR should fit into your clinic process (I recommend Well Care Strategies TPS Full Ambulatory Solution).

Posted in Clinic Management. Tags: , , , . 2 Comments »

Evidence Based Notes on Pressure Ulcers

September 30, 2011 — Matthew Livingston R.N. C.W.S.

NPWT

Negative Pressure Wound Therapy increases rate of closure in stage 3 and 4 pressure ulcers

(Ubbink, Westbos, Evans, Land, & Vermeulen, 2008)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 34

Support Surfaces

Individuals at risk should be placed on a pressure redistribution surface.

(RNAO, 2005; NICE, 2005)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,   Pg 18

Nutrition

Early nutritional assessment is critical to identify patients at risk for malnutrition

(Dorner, Posthauer, & Thomas, 2009)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 10

Surgical Intervention

Evaluate the need for surgical interventions with stage 3 and 4 pressure ulcers that don’t respond to conservative pressure ulcer treatments.

(Sorensen, Jorgensen, & Gottrup, 2004)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 35

Co-morbidities related to delayed healing in Pressure Ulcers

Pressure Ulcer healing is complicated by co-morbid conditions including malignancy, diabetes, CVA, heart failure, renal failure, pneumonia.

(Berlowitz & Wilking, 1989)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

Wound Conditions related to delayed healing in Pressure Ulcers

Wounds that are larger, deeper, infected, had large amount of exudate, and /or covered with slough or eschar are less likely to heal with in 3 months and likely to heal after five to six months of treatment.

(Jones et al., 2007)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

 

Benchmark for Pressure Ulcers greater than 4 square cm

The median days to healing is 73 days for large (>4cm2) ulcers

(Bergstrom et al., 2008)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.

 

Benchmark for Pressure Ulcers greater than 4 square cm

The healing rate for stage 3 pressures was 31.5% and 23.3% for stage 4 pressure ulcers in the first 3 months (12 weeks).

(Brandeis et al., 1990)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.

 

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Teaching New Wound Clinicians

May 15, 2011 — Matthew Livingston R.N. C.W.S.

Education is a key component when adding new nurses to your wound clinic. Getting these nurses up to speed fast is important for the flow of the clinic and the success of the new employee. There are four interconnecting approaches to wound management education including, literature, classroom, internet, and one to one nurse interaction.

I find that it is best not to overwhelm the new nurse in the first week, so I usually send them home with easy reading. My favorite easy reading book for new nurses and students is Wound Care Made Incredibly Visual by Springhouse publishing. This book has very simple content and provides great graphics to enforce the written content.

Before the new nurse starts working with patients I recommend a two or three day (hands on) practicum. Ask representatives from companies that you use to assist you in this process. Consider topics such as how to take photos, how to assess the patient, review charge sheets, general product review, compression bandaging, negative pressure wound therapy, orthopedics, Apligraf, Dermagraft, total contact casts, and special wound products such as Mist therapy.

Posted in Education. 1 Comment »
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