The efficient application of instilling negative pressure wound therapy with a hypochlorous acid-preserved wound cleanser: a case series and practical advice.

BACKGROUND: The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has been shown to be effective in removing nonviable tissue, reducing bioburden, and promoting granulation tissue formation in acute and chronic infected wounds. OBJECTIVE: To illustrate the clinical efficacy of the use of pure hypochlorous acid (pHA) antimicrobially preserved wound cleansing solution as the instillation fluid for NPWTi-d (NPWTi-d/pHA) in wound bed preparation in patients with complex wounds. CASE REPORT: The treatment protocol for use of NPWTi-d/pHA in preparing wound beds for final closure is demonstrated in 3 illustrative cases of patients with complex wounds resulting from necrotizing infection and trauma with heavy contamination. All 3 patients developed a healthy-appearing wound bed deemed suitable for primary closure an average of approximately 1 month following initial surgical debridement. CONCLUSION: The cases presented demonstrate the ability of a pHA antimicrobially preserved wound cleansing solution used as the instillation fluid with NPWTi-d to aid in bacterial reduction, mechanical debridement, and promotion of wound healing. Use of NPWTi-d/pHA in these cases of extensive necrotizing infection and posttraumatic injury with heavy contamination allowed for final closure an average of 1 month after initial surgical debridement.

Time and labor costs of compression therapy wrap system for lower extremity edema: results from a single center.

INTRODUCTION: Compression therapy is the standard of care for the treatment of lower extremity edema. However, compression therapy systems can be time-consuming to apply, which adds costs to the health care system and further strains human resources. OBJECTIVE: The purpose of this study was to assess time and labor costs associated with the application of a 2LB versus 4LB compression therapy system. MATERIALS AND METHODS: Time and labor cost data associated with the application of a 2LB system for the treatment of lower extremity edema of all etiologies were collected from a single high-volume wound care center located in Dayton, Ohio. The time and labor costs were compared to a 4LB system over the course of a single day (n = 38). RESULTS: The application time and associated costs were 50% lower for the 2LB system. The expected savings of a 2LB compression system over the course of a month was 16:27 hours and $427 compared to a 4LB compression system, and the revenue gain was estimated at $15 210 revenue per month over the course of the month for the practice. CONCLUSION: The use of a 2LB compression system may be associated with substantial time and cost savings compared to a 4LB system.

Management of Moisture-Associated Skin Damage: A Scoping Review.

BACKGROUND: Protecting the skin against moisture-associated damage is an important component of comprehensive skin and wound care. Based on a review of literature, the authors propose key interventions to protect and prevent damage in the skin folds, perineum, and areas surrounding a wound or stoma. OBJECTIVE: The aim of this scoping review is to identify and provide a narrative integration of the existing evidence related to the management and prevention of moisture-associated skin damage (MASD). METHODS: Study authors searched several databases for a broad spectrum of published and unpublished studies in English, published between 2000 and July 2015. Selected study information was collated in several different formats; ultimately, key findings were aggregated into a thematic description of the evidence to help generate a set of summative statements or recommendations. RESULTS: Based on inclusion criteria, 37 articles were considered appropriate for this review. Findings included functional definitions and prevalence rates of the 4 types of MASD, assessment scales for each, and 7 evidence-based strategies for the management of MASD. CONCLUSIONS: Based on this scoping review of literature, the authors propose key interventions to protect and prevent MASD including the use of barrier ointments, liquid polymers, and cyanoacrylates to create a protective layer that simultaneously maintains hydration levels while blocking external moisture and irritants.

The Compatibility of Chlorhexidine and a Skin Care Product Line: A Real-World Analysis of Hospital-Acquired Infection Rates.

Chlorhexidine gluconate (CHG) use helps reduce hospital-acquired infections (HAIs). Chlorhexidine gluconate effectiveness can be reduced by use of skin care products. Although laboratory work can be performed to prove compatibility, such work has limitations. The purpose of this study was to compare HAI rates when CHG antiseptic wipes were used in conjunction with a silicone- and micronutrient-based skin care product line (SMSP) and when CHG wipes were used without the SMSP. Using commercial distribution data, 17 hospitals that purchased both CHG wipes and SMSP were identified. Hospital-acquired infection rates from this group were compared with HAI rates from 18 hospitals that used CHG wipes, but not SMSP. Hospital-acquired infection information was obtained from the Leapfrog Group (www.hospitalsafetyscore.org/). Four infection rates were compared: (1) infection in the blood during an intensive care unit stay, (2) infection in the urinary tract during an intensive care unit stay, (3) surgical site infection after colon surgery, and (4) average infection rate from 1 to 3. There was no significant difference between the infection rates of the two groups (Ps ranged from .285 to .983). There was also no statistically significant association between hospital grade and product use (P = .194). When considering publicly available data on HAI, there was no measurable difference in HAI rates between facilities that use CHG wipes with or without an SMSP. The SMSP does not impact the efficacy of CHG wipes.

Evaluation of a bovine 100% native collagen for the treatment of chronic wounds: a case series.

PURPOSE: The roles of debridement, infection control, and moisture balance in wound healing are familiar to wound care clinicians, but these measures may not be sufficient for wound closure in all patients. In these cases, adjuvant therapies such as collagen dressings may be needed. Collagen dressings are thought to encourage wound healing by laying down a provisional biomaterial matrix that captures wound exudates because of its absorbent nature, and thus creates an environment necessary for healing. This case series describes our experience with a bovine-derived, 100% native, type I collagen in patients with chronic and persistent wounds. CASES: This case series included 20 patients with 21 chronic wounds ranging from 0.6 to 101.4 cm(2) that had been recalcitrant to prior conservative treatment and/or the use of submucosal intestinal matrix, oxidized regenerated cellulose/collagen matrix, or skin substitute. In addition to the bovine-derived 100% native collagen, standard wound care included the use of any systemic or topical antimicrobial treatments needed to specifically address wound infections. The total duration of treatment with the bovine-derived 100% native collagen was up to 12 weeks. Complete wound healing was achieved for 15 of the patients in this series; wound healing times varied from 13 to 68 days. Two additional patients achieved wound healing, using a combination of the bovine-derived 100% native collagen and other therapies, at 114 days and 107 days, respectively, after starting the wound healing process with solely the bovine-derived 100% native collagen treatment. One patient did not respond to treatment. The collagen treatment was well tolerated by the patients, with 3 incidences of dermatitis that resolved after treatment with corticosteroids. CONCLUSION: Following a change in their chronic wound care regimen to include a bovine-derived, 100% native, type I collagen, we achieved an 83.3% (15 out of 18 patients) wound closure rate. Two patients were excluded from the data set analysis because they received additional intervention outside the parameters described in this multiple-case series.

A Single Long-Term Acute Care Hospital Experience with a Pressure Ulcer Prevention Program.

PURPOSE: The occurrence of pressure ulcers (PrUs) challenges care facilities. Few studies report PrU reduction efforts in long-term acute care (LTAC). This study described the PrU reduction efforts of a single, LTAC facility using the Medline Pressure Ulcer Prevention Program (mPUPP). DESIGN: This study was a quasi-experimental, quality improvement project, with pre- and postmeasurement design. METHODS: Outcomes were tracked for 24 months. The mPUPP was implemented in month 11. Education for caregivers was provided through an interactive web-based suite. In addition, all Patient Care Technicians attended a 4-week 1-hour inservice. New skin care products were implemented. The facility also implemented an algorithm for treatment of wounds. FINDINGS: There was a significant reduction in the mean monthly hospital-acquired PrU (nPrU) rate when preprogram is compared to postprogram. CONCLUSIONS: Sustainable nPrU reduction can be achieved with mPUPP. CLINICAL RELEVANCE: LTAC hospitals could expect to reduce nPrU with education and incentive of caregivers.

Skin care product evaluation in a group of critically ill, premature neonates: a descriptive study.

PURPOSE: Cleansing, moisturizing, and protecting neonatal skin is important, but literature evaluating specific product lines is limited. The purpose of this study was to measure the influence of a skin care product line on overall skin condition, perineal erythema, and pain when applied to neonates in a neonatal intensive care unit (NICU). DESIGN: This was an open label, descriptive study. Comparisons were made between measurements taken at the beginning of the study to those at the end, on the same subjects. SUBJECTS AND SETTING: The study was conducted in a 41-bed NICU at Driscoll Children's Hospital in Corpus Christi, Texas, that serves 31 counties in the region. This NICU treats children needing level 2 and 3 care, with a 1:1 or 2:1 nurse staffing ratio. This is not a birthing center; patients come from other community hospitals. Twenty-nine neonates participated in the study; their average body weight was 1.39 kg (3.06 lb) and their average gestation was 31.7 weeks. METHODS: A skin care product line was introduced into a neonatal intensive care unit for 14 days. The products included 2 cleansers, 2 moisturizers, and a skin protectant with zinc oxide. Three outcome measures were tracked: Neonatal Skin Condition Score (NSCS), Skin Erythema Scale (SES), and pain. Nurses were also given a product evaluation survey. Descriptive statistics were used to report percentages and trends. Paired t tests were used to compare the mean NSCS, SES, and pain scores from the first 2 days a subject was in the study to the mean of the scores from the last 2 days they were in the study. RESULTS: Subjects experienced approximately 1774 exposures to individual products during data collection. No differences were found in pain scores (P = .132), SES score (P = .059), or NSCS (P = .603) when mean values were compared at the beginning and end of the study. Analysis of the product evaluation survey for questions on cleaning, moisturizing, and reducing discomfort found that more than 90% of nurses ranked the new products as better than or equal to similar products used previously. CONCLUSIONS: Use of a skin care product line was not associated with significant increases in overall neonatal skin condition measured with the NSCS, perineal erythema measured with the SES, or pain. The nurses caring for the subjects in this study prefer these products to others they have used in the past.

A laboratory comparison between two liquid skin barrier products.

Exposure of skin to friction and moisture is detrimental to skin health. The purpose of this experimental study was to investigate the ability of a cyanoacrylate polymer film to protect human skin against moisture and abrasion. A secondary purpose of this study was to compare this cyanoacrylate material to a traditional barrier film. Twelve healthy subjects participated in the wash-off resistance test to determine the percentage of dye that was left on the skin after repeated washing. Ten subjects participated in the abrasion test. Transepidermal water loss (TEWL) was measured before and after abrasion to determine the level of skin damage, as high water loss seen post-abrasion is indicative of skin damage post-abrasion. Skin treated with cyanoacrylate had significantly more dye remaining than sites treated with traditional film barrier or control sites. The change in TEWL was statistically lower for cyanoacrylate-treated areas.

A controlled laboratory comparison of 4 topical skin creams moisturizing capability on human subjects.

PURPOSE: This study compares human skin capacitance (moisture) readings after the application of 4 different, commercially available, topical skin creams. SUBJECTS AND SETTING: Twenty-one subjects (15 women and 6 men) aged 49.38 ± 11.02) years (mean ± SD) participated. This study was conducted in a climate-controlled laboratory on healthy human subjects. DESIGN: Randomized experimental study comparing 4 topical skin creams for their effect on human skin capacitance (moisture). METHODS: Subject forearm skin was conditioned for 7 days prior to testing by washing with a standard soap and application of no other products. Each subject was marked with 5 test sites on the forearms. Sites on the volar surface of each subject's forearms were randomly assigned for application of 1 of 4 product pairs, consisting of a cleanser and a topical skin cream or a control site. A Corneometer was used to measure skin capacitance. Each site on the arms was cleaned and dried, tested again for moisture content, subjected to topical skin cream application, and finally tested again for moisture content. Changes were measured by subtracting the capacitance readings at baseline from values measured following topical skin cream application for each test site. RESULTS: The mean change in capacitance was 13.9 for product 1, 10.3 for product 3, 8.7 for product 2, 1.6 for product 4, and 0.8 for the control site. The mean capacitance change in sites treated with product 1 (13.9 ± 8.0, mean ± SD) was significantly greater than all others. There was no difference between the change in capacitance of product 2 (mean = 8.7, SD = 4.9) and product 3 (10.3 ± 7.1) t(20) = 1.081, P = .293, nor between product 4 (1.6 ± 3.9) and the control site (0.3, ± 2.2) t(20) = 0.779, P = .445. The capacitance change of products 2 and 3 was greater than that of product 4 and the control site. CONCLUSIONS: Commercially available topical skin creams vary in their impact on human skin capacitance. In this study, sites tested with product 1 had a greater skin capacitance reading than the other tested products; products 2 and 3 had similar capacitance readings. The results of this study provide an initial evaluation of topical skin creams that have varying impacts on skin capacitance.

The Use of a Pure Native Collagen Dressing for Wound Bed Preparation Prior to Use of a Living Bi-layered Skin Substitute.

Management of chronic wounds in the outpatient setting is quite challenging. The extensive co-morbid medical problems of the chronically ill patient along with the complexities of the wound bed and its biochemical environment has led to a plethora of patients with poor wound healing. This ever increasing population is a challenge for the wound care practitioner and cost to the health care system and patient. Increased wound chronicity has promulgated the use of advanced wound care products, including Living Skin Substitutes (LSS), in an attempt to obtain wound closure, and ultimately both physiological and functional healing.(1-3) In the outpatient setting, it is evident that the efficacy of the LSS varies widely depending on the patient type with some patients responding quite favorably while others who do not achieve healing despite repeated applications of LSS. This case series demonstrates that a systematic method of wound bed preparation prior to the application of LSS improved healing outcomes. The entire wound bed preparation protocol included autolytic, non-selective, and sharp-selective debridement, if deemed appropriate, followed by the weekly application of a pure native collagen. The wound bed preparation protocol was completed prior to LSS application. This case series presents evidence supporting the application of a 100% native collagen dressing to wound bed prior to the final step of LSS utilization.

Pressure Ulcer Prevention Program Study: a randomized, controlled prospective comparative value evaluation of 2 pressure ulcer prevention strategies in nursing and rehabilitation centers.

OBJECTIVE: This article assesses the comparative prevention-effectiveness and economic implications of a Pressure Ulcer Prevention Program (PUPP) against standard practice of prevention using Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) guidelines and a mixture of commercial products. DESIGN: The study is a randomized, controlled, prospective cohort study with an accompanying economic evaluation. The economic evaluation is performed from the perspective of the nursing and rehabilitation centers. SETTINGS: Two nursing and rehabilitation centers under the same quality and safety support organization. Both institutions are experiencing high nursing staff turnover and incidence of pressure ulcers (PrUs). PARTICIPANTS: 133 residents at risk of developing PrUs (EQUIP-for-Quality Risk Score Moderate to Very High [MVH]). All are Medicare-eligible residents with Minimum Data Set (MDS) 2.0 evaluations. INTERVENTIONS: The PUPP includes a strategic product bundle and decision algorithms driven by MDS 2.0 Resident Assessment Scores to assist in reducing or preventing PrUs and incontinence-associated skin conditions. The control group utilizes a different brand and assortment of commercial skin care products, briefs, pads, and mattresses, but without use of the decision algorithms driven by MDS 2.0 Resident Assessment Scores. Pressure ulcer prevention education was done for all nurses by a nurse certified in the PUPP program at the beginning and ad libitum by trained senior nursing staff at the end of the study. MAIN OUTCOME MEASURES: Comparative reduction in the incidence of nosocomial PrUs and average 6-month net cost savings per MVH-risk resident. METHODS: Residents were assessed for PrU risk using EQUIP-for-Quality risk assessment algorithm based on data from their Minimum Data Set (MDS 2.0), then assigned to either the PUPP program or control group (standard practice following AHRQ guidelines). Residents were followed until discharge, death, development of PrU, or a maximum time period of 6 months. Direct medical costs of prevention and PrU treatment were recorded using a modified activity-based costing method. A decision model was used to estimate the net cost savings attributed to the PUPP program over a 6-month period. RESULTS: A 67% reduction in the incidence of nosocomial pressure ulcers is attributable to the PUPP strategy over a 6-month period for MVH residents. The average 6-month cost for a MVH Medicare resident is $1928 and $1130 for the control group and PUPP group respectively. Mean difference (net cost savings per resident at risk of pressure ulceration) is $798 per resident for PUPP. CONCLUSIONS: PUPP assisted in reducing the incidence of PrUs by 67% in a 6-month period in nursing home facilities. The estimated annual net cost savings attributed to PUPP for 300 MVH residents is estimated at approximately $240,000.

An evaluation of costs and effects of a nutrient-based skin care program as a component of prevention of skin tears in an extended convalescent center.

PURPOSE: A decision model was developed in a pilot study comparing a regimen using a skin care product line containing active ingredients and nutrients with a commercially available alternative skin care regimen in an elderly convalescent care hospital-based center. METHODS: Using a decision-tree model, skin treatment with a nutrient-based skin care (NBSC) formulation was compared with products without nutrients. The number of skin-tear-free days was the primary outcome measure. A cost-effectiveness ratio was calculated for each skin treatment as the average cost for reaching a particular outcome. Incidence of skin tear data was collected from residents in a convalescent center from 2004 to 2005. An independent t test was used to compare differences in the number of skin tears between periods when NBSC and other formulations were used. All costs in the decision model were adjusted to 2007 dollars. Sensitivity analysis was used to test uncertain data. RESULTS: The NBSC provided more skin-tear-free days and was less costly than the use of non-NBSC products. The expected skin-tear-free days for a patient in the model treated with NBSC were 179.7 days compared with 154.6 days for non-NBSC products, yielding an incremental effect of 25.1 days. The expected cost of preventing skin tears and treatment via skin treatment per patient in the NBSC group was $281.00 versus $324.10 for periods when other products were used. CONCLUSION: The NBSC had a lower projected cost for prevention of skin tears and more skin-tear-free days when compared with non-NBSC products.

A review of cyanoacrylate liquid skin protectant and its efficacy on pedal fissures.

INTRODUCTION: Skin fissures are a common dermatologic condition caused by excessive dry skin, numerous systemic diseases, and backless shoe gear. They are defects in skin that fall into the category of damaged, partial-thickness skin wounds, as opposed to full-thickness wounds. Patients with heel fissures are at an increased risk for developing infection, which could cause more severe issues, especially in patients with diabetes and peripheral vascular disease. METHODS: Five patients from Temple Foot and Ankle Institute, Philadelphia, PA, with a total of 8 heel fissures and 2 hallux fissures, were studied. Patients were dispensed 9 vials of a cyanoacrylate liquid skin protectant (Marathon(™), Medline Industries, Inc, Mundelein, IL) to be applied to the fissure every 3 days. Patients returned every 2 weeks for follow-up in clinic. RESULTS: The hallux fissures and 4 of the heel fissures went to complete closure after 2 weeks. There was an average decrease of 1.16 cm in length of the heel fissure dimensions after 2 weeks and an average decrease of 1.1 cm in length of the hallux fissures. CONCLUSION: This novel skin protectant proved to be a comfortable, easy, and effective tool in aiding the resolution of pedal skin fissures.

Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen.

OBJECTIVE: To determine the effect of a silicone-based dermal nourishing emollient (SBDNE) regimen on the reduction of pressure ulcers (PrUs) and costs in a hospital medical unit. RATIONALE: PrUs represent a serious problem for patients within the acute care setting and are a significant care management challenge for clinicians. Effective October 1, 2008, the Centers for Medicare and Medicaid Services will no longer reimburse hospitals at the higher diagnosis-related group rate for Stages III and IV PrUs that are not documented on admission. In addition, formation of PrUs in the hospital also puts the institution at financial risk of lawsuits. RESEARCH DESIGN AND METHODS: The wound healing center at Porter Adventist Hospital, Denver, Colorado, documented the hospital-acquired incidence rate of PrU patients in the hospital from May 2006 to December 2007. A retrospective, quasi-experimental design was used to examine the changes in PrU incidence rates and the economic effect of introducing a SBDNE regimen into an existing PrU prevention protocol. RESULTS: The replacement of a mixture of ad hoc skin care products, none of which contained silicone-based emollients, with an SBDNE skin care regimen into an existing prevention program significantly reduced the proportion of hospital-acquired PrUs to 0% after 8 months. Estimated cost savings per patient admitted to the medical unit attributed to SBDNE averaged $6677.11 per patient. MAIN CONCLUSIONS: The use of an SBDNE skin care regimen was important in bringing about a significant reduction in the number of patients with PrUs and respective treatment costs in a medical unit experiencing high incidence rates of PrUs.

Effect of a water-based no-sting, protective barrier formulation and a solvent-containing similar formulation on skin protection from medical adhesive trauma.

Trauma to the skin from repeated removal of adhesive-based medical products can cause pain, anxiety, risk of secondary infections and additional health care costs. Skin barrier formulations are used to protect the integrity from such trauma. However, not all formulations are equally protective. We report the results of a randomised controlled study comparing a solvent-free (SF) formulation and a solvent-containing (SC) formulation to the skin of 12 healthy volunteers aged 18-55 years. Treatments were applied at baseline to two of the four test sites on the back of each subject and repeated for 5 days. Measurements of pain, discomfort, erythema and skin water loss were taken 24 hours after each application. The SF formulation is associated with lower mean scores for erythema (day 5, P < 0.05) and lower values for transepidermal water loss (day 5, P < 0.05) and redness (days 4 and 5, P < 0.05) when compared with either no treatment or daily treatment with a SC formulation. There were no significant differences between subject responses when pain on application of the test formulation or discomfort associated with removal of the medical adhesive tapes were rated. We conclude that a SF formulation provides better security against adhesive-derived skin trauma than a SC formulation.