Resource requirements for a quality Doctor of Nursing Practice program.

Fundamental to planning, implementing, and sustaining a quality Doctor of Nursing Practice (DNP) program is access to the resources needed to foster a learning environment that prepares nurses for advanced practice and leadership in the future redesigned health care system. This creates formidable challenges for schools and colleges of nursing as they endeavor to address the nation's need for an increased supply of advanced practice nurses to provide access to high-quality, cost-effective care for an aging population. This article describes the essential resources needed to support the delivery of a DNP program and the proposed strategies needed to address the resource challenges.

Head-of-bed elevation in critically ill patients: a review.

Clinicians are confused by conflicting guidelines about the use of head-of-bed elevation to prevent aspiration and pressure ulcers in critically ill patients. Research-based information in support of guidelines for head-of-bed elevation to prevent either condition is limited. However, positioning of the head of the bed has been studied more extensively for the prevention of aspiration than for the prevention of pressure ulcers, especially in critically ill patients. More research on pressure ulcers has been conducted in healthy persons or residents of nursing homes than in critically ill patients. Thus, the optimal elevation for the head of the bed to balance the risks for aspiration and pressure ulcers in critically ill patients who are receiving mechanical ventilation and tube feedings is unknown. Currently available information provides some indications of how to position patients; however, randomized controlled trials where both outcomes are evaluated simultaneously at various head-of-bed positions are needed.

Volume Measures Using a Digital Image Analysis System are Reliable in Diabetic Foot Ulcers.

UNLABELLED: Reliable measures of wound size are critical to wound healing research and clinical management. Measurement of full-thickness wounds is increasingly being done using digital images and photogrammetric software, such as VeVMD (Vista Medical, Winnipeg, Manitoba, Canada), to estimate wound volume. The reliability of VeVMD in determining wound volume is unknown. The present study sought to examine the reliability of wound volume measurements obtained using VeVMD. METHODS: A cross-sectional study of adults with full-thickness, neuropathic, diabetic foot ulcers (DFU) at 2 sites in the US Midwest was undertaken. Ulcer images were obtained, stored, and used to obtain measures of wound volume using VeVMD. Four raters independently completed wound measures, and then repeated these measures 2 weeks after the first measurement. Raters were blinded to the comparison measurements. Inter- and intra-rater correlations were computed. RESULTS: Thirty-three enrolled subjects with 33 DFU were included in the analyses. Inter-rater reliability was 0.745 and intra-rater reliability was 0.868. Four ulcers showed noticeably less agreement between raters; these ulcers had small, but deeply recessed areas, resulting in differences in defining the wound margin. When these 4 ulcers were removed, inter- and intra-rater reliabilities were excellent (0.970 and 0.981, respectively). CONCLUSION: Reliabilities of volume measurements obtained with VeVMD were acceptable in DFU, even when raters had different definitions of the ulcer margin or changed their definition from time to time. However, conclusions cannot be drawn regarding the performance of VeVMD in other wound types.

A prospective study of the PUSH tool in diabetic foot ulcers.

PURPOSE: The purpose of this study was to examine the predictive validity of Pressure Ulcer Scale for Healing (PUSH; v. 3.0) in monitoring healing of neuropathic foot ulcers in patients with diabetes mellitus. DESIGN: This is a 13-week descriptive, prospective study describing the trajectory of change over time and the time-to-heal associated with PUSH scores. The study monitored a convenience sample of 18 subjects with Wagner 2 or greater neuropathic, nonischemic ulcers on the plantar surface of the foot, which healed completely over a 13-week follow-up period. Every 2 weeks, the study ulcers were evaluated via PUSH. Healing was defined as complete reepithelialization. RESULTS: PUSH scores were modeled using a piecewise linear regression. PUSH values decreased significantly (P < .0001) at a rate of 0.6656 per week, until 2 weeks before healing, and then decreased significantly (P < .0001) at a rate of 2.2496 per week for the last 2 weeks of healing. Conversely, the time-to-heal (in weeks) increased significantly (P < .0001), at a rate of 0.6412 per each unit increase in PUSH for PUSH values of 4 or less, and then significantly (P < .0001) increased at a rate of 1.072 for PUSH values greater than 5. In predicting time-to-heal, the subitem of length × width alone (R = 0.81) is comparable to the total PUSH score (R = 0.76). Individually, exudate (R = 0.36) and tissue type (R = 0.42) are not nearly as useful as length × width. CONCLUSION: Our findings indicate that PUSH scores significantly decrease over time in healing neuropathic diabetic foot ulcers (DFUs) that have no arterial etiologic component. Findings also suggest that total PUSH scores predict time-to-heal for DFU. We showed that a DFU with a PUSH score of 10 would be expected to heal in 8.8 weeks (95% CI: 7.4-10.2) and a DFU with a PUSH score of 4 in 2.6 weeks (95% CI: 1.88-3.25). Finally, measurements of size alone predict healing time for neuropathic DFU. This finding could greatly simplify clinical assessments.

Clinical signs of infection in diabetic foot ulcers with high microbial load.

AIMS: One proposed method to diagnose diabetic foot ulcers (DFUs) for infection is clinical examination. Twelve different signs of infection have been reported. The purpose of this study was to examine diagnostic validity of each individual clinical sign, a combination of signs recommended by the Infectious Disease Society of America (IDSA), and a composite predictor based on all signs of localized wound infection in identifying DFU infection, among a sample of DFUs. METHODS: A cross-sectional research design was used. Sixty-four individuals with DFUs were recruited from a Department of Veterans Affairs Medical Center and an academic-affiliated hospital. Each DFU was independently assessed by 2 research team members using the clinical signs and symptoms checklist. Tissue specimens were then obtained via wound biopsy and quantitatively processed. Ulcers with more than 106 organisms per gram of tissue were defined as having high microbial load. Individual signs and the IDSA combination were assessed for validity by calculating sensitivity, specificity, and concordance probability. The composite predictor was analyzed using c-index and receiver operating curves. RESULTS: Twenty-five (39%) of the DFUs had high microbial loads. No individual sign was a significant predictor of high microbial load. The IDSA combination was not a significant predictor either. The c-index of the composite predictor was .645 with a 95% confidence interval of .559-.732. CONCLUSIONS: Individual signs of infection do not perform well nor does the IDSA combination of signs. However, a composite predictor based on all signs provides a moderate level of discrimination, suggesting clinical use. Larger sample sizes and alternate reference standards are recommended.

Wound bioburden and infection-related complications in diabetic foot ulcers.

The identification and diagnosis of diabetic foot ulcer (DFU) infections remains a complex problem. Because inflammatory responses to microbial invasion may be diminished in persons with diabetes, clinical signs of infection are often absent in persons with DFUs when infection is limited to localized tissue. In the absence of these clinical signs, microbial load is believed to be the best indicator of infection. Some researchers, however, believe microbial load to be insignificant and type of organism growing in the ulcer to be most important. Previous studies on the microbiology of DFUs have not provided enough evidence to determine the microbiological parameters of importance.Infection-related complications of DFUs include wound deterioration, osteomyelitis, and amputation. Risk factors for amputation include age, peripheral vascular disease, low transcutaneous oxygen, smoking, and poor glycemic control. These risk factors are best measured directly with physiological measures of arterial perfusion, glycemic control, sensory neuropathy, plantar pressures, and activity level and by controlling off-loading. DFU bioburden has not been examined as a risk factor for infection-related complications. To address the relationship between wound bioburden and the development of infection-related complications in DFUs, tightly controlled prospective studies based on clearly defined, valid measures of wound bioburden and wound outcomes are needed. This article reviews the literature and proposes a model of hypothesized relationships between wound bioburden-including microbial load, microbial diversity, and pathogenicity of organisms-and the development of infection-related complications.

The inter-rater reliability of the Clinical Signs and Symptoms Checklist in diabetic foot ulcers.

The Clinical Signs and Symptoms Checklist is a tool designed to measure 12 clinical signs and symptoms of localized chronic wound infection. Since its initial development, this Checklist has been revised to include sanguineous drainage. To examine the inter-rater reliability of the revised Clinical Signs and Symptoms Checklist in diabetic foot ulcers, an observational, cross-sectional study was conducted in conjunction with a larger study examining the validity of each sign and symptom for identifying infection in diabetic foot ulcers. Two independent nurse observers assessed 64 diabetic foot ulcers in 64 patients using the Checklist. The reliability of each item was calculated using percent agreement and the Kappa coefficient. Total percent agreement ranged from 76% to 100%, and Kappa statistics ranged from .34 to 1.00. Study findings confirm that the Clinical Signs and Symptoms Checklist is a reliable tool for identifying the clinical signs and symptoms of localized infection in diabetic foot ulcers.

Diagnostic Validity of Semiquantitative Swab Cultures.

Swab cultures of wounds are noninvasive and most laboratories are capable of semiquantitatively processing these specimens. This study examined the diagnostic validity of semiquantitative swab cultures obtained using Levine's technique and compared semiquantitative and quantitative swab cultures. Two swab specimens were obtained from a sample of 44 chronic wounds using Levine's technique. One was processed using quantitative laboratory procedures and the other using semiquantitative laboratory procedures. The diagnostic validity of the findings from each swab culture process was determined by associating the culture findings of each with quantitative tissue cultures (reference standard) using receiver operating characteristic (ROC) curves and by evaluating concordance. The area under the curve (AUC) of the semiquantitative swab culture was 0.639, which was not significantly higher than the .50 diagonal chance (P = 0.0501), suggesting a non-informative test. The AUC for quantitative swab cultures was 0.821. The AUC of the quantitative swab culture was significantly higher than the diagonal chance line of 0.5 and was significantly higher than the AUC of the semiquantitative swab culture (P = 0.0128). The mean concordance of semiquantitative cultures in recovering all organisms was 57%. The mean concordance of quantitative swab cultures in recovering all organisms was 72%. The findings of this study suggest that swab specimens processed using semiquantitative processes do not provide culture findings that correlate well with culture findings from tissue specimens. More meaningful information can be obtained from swab specimens if they are quantitatively processed in the laboratory.

Diagnostic validity of three swab techniques for identifying chronic wound infection.

This study examined the diagnostic validity of three different swab techniques in identifying chronic wound infection. Concurrent swab specimens of chronic wounds were obtained using wound exudate, the Z-technique, and the Levine technique, along with a specimen of viable wound tissue. Swab and tissue specimens were cultured using quantitative and qualitative laboratory procedures. Infected wounds were defined as those containing 1 x 10(6) or more organisms per gram of tissue. Accuracy was determined by associating the quantitative cultures of swab specimens with the cultures from tissue specimens using receiver operating characteristic curves. Of the 83 study wounds, 30 (36%) were infected. Accuracy was the highest for swab specimens obtained using Levine's technique at 0.80. Based on Levine's technique, a critical threshold of 37,000 organisms per swab provided a sensitivity of 90% and a specificity of 57%. The mean concordance between swab specimens obtained using Levine's technique and tissue specimens was 78%. The findings suggest that swab specimens collected using Levine's technique provide a reasonably accurate measure of wound bioburden, given that they are more widely applicable than tissue cultures. The diagnostic validity of Levine's technique needs further study using an alternative reference standard, such as the development of infection-related complications.

New distribution records of Echinococcus multilocularis in the brown lemming from Barrow, Alaska, USA.

We identified Echinococcus multilocularis for the first time in brown lemmings (Lemmus trimucronatus) from Barrow, Alaska, USA. Of 467 brown lemmings trapped between 1995 and 2000, two males and two females (0.9%; 95% confidence interval=0.9+/-0.9%) were found to be infected with metacestodes of E. multilocularis. No metacestodes were found in 17 collared lemmings (Dicrostonyx rubricatus) also trapped at Barrow. In humans, E. multilocularis causes alveolar echinococcosis, which is potentially fatal. Knowledge of the distribution of this parasite is important to protect the public health.

A prospective study of the pressure ulcer scale for healing (PUSH).

BACKGROUND: Although the recently developed Pressure Ulcer Scale for Healing (PUSH) was created to monitor healing over time, prospective evidence of its validity in measuring healing is lacking. The purpose of this study was to assess the validity of PUSH (version 3.0) when used to assess pressure ulcers in clinical practice. METHODS: The authors chose a prospective research design using a convenience sample of nursing home residents with pressure ulcers. The patients' pressure ulcers were assessed each week with the PUSH and the Pressure Sore Status Tool. Surface area measurements derived from wound tracings were also obtained. Weekly assessments continued until the ulcer healed, the resident died, the resident transferred from the nursing home, or 6 months of assessments were complete. RESULTS: Thirty-two pressure ulcers comprised the study sample. Twenty-one (66%) healed during the 6-month study period and 11 (34%) did not heal. The PUSH scores decreased significantly over time among the healed ulcers but did not among the unhealed ulcers. Similarly, PUSH scores were significantly lower among the healed compared with the unhealed ulcers. Finally, total scores on PUSH were highly correlated with both the Pressure Sore Status Tool and surface area measurements. CONCLUSIONS: The PUSH provides a valid measure of pressure ulcer healing over time and accurately differentiates a healing from a nonhealing ulcer. It is a clinically practical, evidence-based tool for tracking changes in pressure ulcer status when applied at weekly intervals.

Effect of initial weight-bearing in a total contact cast on healing of diabetic foot ulcers.

BACKGROUND: Although total contact casts are highly effective in the treatment of plantar ulcerations in patients with diabetes mellitus, they are not widely used. One reason for this lack of acceptance may be the difficulty in complying with an initial period of non-weight-bearing, as is generally recommended by physicians. We performed this study to assess the effects of early weight-bearing on the healing rates of plantar ulcers in patients with diabetes who were wearing a total contact cast. METHODS: Forty patients with diabetes mellitus who had a noninfected forefoot or midfoot ulcer were treated with total contact casts until healing or for thirteen weeks. The patients were instructed to bear no weight on the cast for forty-eight hours after it was applied. Using an embedded step counter, we measured the number of steps taken during the first twenty-four and forty-eight hours, the first week, and each subsequent two-week period after application of the cast. We removed the cast, measured the radius of the ulcer, and then reapplied the cast at the end of the first week and of each subsequent two-week period after cast application until the ulcer healed or for thirteen weeks. We then determined the effect of the number of steps during various time intervals on the rate of ulcer healing (defined as a change in the ulcer radius). RESULTS: Most patients walked on the cast in the immediate postoperative period. The effects of modest amounts of early weight-bearing on ulcer healing rates appear negligible. Only excessive walking during the first twenty-four or forty-eight hours after cast application is likely to prolong the duration of cast treatment. CONCLUSIONS: Moderate early weight-bearing retards healing of plantar ulcers only minimally in patients with diabetes mellitus treated with total contact casts. Allowing patients to walk immediately after placement of a total contact cast may improve their acceptance of this form of therapy. LEVEL OF EVIDENCE: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Evidence-based protocol. Treatment of pressure ulcers.

Those who provide direct care to older adults with pressure ulcers play a significant role in ensuring the environment is optimal for wound healing. Use of the evidence-based guideline "Treatment of Pressure Ulcers" (Folkedahl, Frantz & Goode, 2002b) can provide a template for implementation of interventions to maximize the repair process.

4.5-gram monofilament sensation beneath both first metatarsal heads indicates protective foot sensation in diabetic patients.

BACKGROUND: Loss of protective plantar foot sensation is the major cause of diabetic foot ulcerations and ultimate limb loss. Identification of patients without protective sensation can reduce the risk of unrecognized foot injury. The current recommended screening protocol requires 10-g monofilament testing of ten foot sites with use of a forced-choice paradigm. The objective of the present study was to determine whether testing of fewer than ten sites could provide accuracy comparable with that obtained by testing all ten sites. METHODS: A cross-sectional comparative study of plantar sensory levels in diabetic subjects with and without plantar ulceration was conducted in a tertiary-care teaching hospital setting. We examined forty-seven diabetic subjects with a history of foot ulceration and forty-five diabetic subjects with no history of foot ulceration. Plantar sensory threshold values at five sites on the sole of each foot were measured with a quasi-continuous range of applied forces, and receiver operating characteristic analysis techniques were applied. RESULTS: Screening on the basis of only the maximum force threshold for the left and right first metatarsal head sites provided comparable or better performance at high levels of sensitivity than did either the mean or the maximum force threshold across all ten sites. A sensory threshold of 4.5 g for both the left and right first metatarsal head sites predicted the risk of ulceration with a sensitivity of 100% and a specificity of 67%. CONCLUSIONS: Testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament. If a patient cannot sense the application of a 4.5-g monofilament under either first metatarsal head, he or she probably has lost protective sensation and should be considered to be at risk for undetected injury.

Evidence-based protocol: prevention of pressure ulcers.

Those who provide direct care to older individuals who are functionally impaired and immobilized must be constantly vigilant for the potential development of pressure ulcers. Use of the evidence-based guideline "Prevention of Pressure Ulcers" (Folkedahl et al., 2002) can provide a template for identification of patients at risk and implementation of interventions to prevent their occurrence.

The effects of total contact casting materials on plantar pressures.

The plaster-based total contact cast (TCC) is effective at reducing high plantar pressures associated with foot ulceration in the patient with diabetes. However, the weight and the lengthy drying time which require nonweightbearing create an inconvenience for the patient. Fiberglass has been commonly used as a substitute for plaster due to the quicker drying time, although little is known about the effects of fiberglass on plantar pressures. The purpose of the study was to compare a plaster-based TCC (PB-TCC) and an all-fiberglass TCC (AF-TCC) using selected plantar pressure parameters for commonly ulcerated regions of the foot. Using a repeated measures design, 10 healthy subjects consented to walk, for four consecutive trials, along a 25-m corridor while wearing a running shoe, PB-TCC, and AF-TCC. For each of the footwear conditions, parameters of peak pressure, pressure-time integral, and contact time for the forefoot, lateral midfoot, and heel regions were recorded using the Pedar trade mark system of plantar pressure measurement. Both the PB-TCC and AF-TCC produced similar peak plantar pressures that were significantly lower (p =.001) than the running shoe. Pressure-time integrals were similar for all footwear conditions and contact time was not altered with footwear type. In summary, the AF-TCC appears to be an effective alternative to the PB-TCC for plantar pressure reduction in the management of neuropathic foot ulceration.

Effectiveness of transcutaneous electrical nerve stimulation on postoperative pain with movement.

This study tested the effectiveness of episodic transcutaneous electrical nerve stimulation (TENS) as a supplement to pharmacologic analgesia on pain with movement and at rest after abdominal surgery and evaluated whether its use during walking and vital capacity maneuvers enhances performance of these activities. TENS, with a modulated frequency, intensity as high as the subject could tolerate, and electrodes placed on either side and parallel to the incision, was compared to placebo TENS and pharmacologic analgesia alone (control) by using a crossover design. Self-report of pain intensity, walking function, and vital capacity were assessed on 33 subjects. TENS resulted in significantly less pain than the control during both walking (P <.5) and vital capacity activities (P <.1) and significantly less pain than placebo TENS during vital capacity (P <.01). TENS also produced significantly better gait speeds than the control (P <.05) and greater gait distances (P <.01) than the control and placebo TENS. Vital capacity and pain intensity at rest were not significantly different among the 3 treatments. These results suggest TENS reduces pain intensity during walking and deep breathing and increases walking function postoperatively when used as a supplement to pharmacologic analgesia. The lack of effect on pain at rest supports the hypothesis that TENS works through reducing hyperalgesia.

Implementing an incontinence management protocol in long-term care. Clinical outcomes and costs.

This article describes clinical outcomes and costs of implementing an incontinence management protocol based on the recommendations contained in the Agency for Health Care Quality and Research clinical practice guidelines on incontinence and pressure ulcer prevention. Following implementation of the protocol, 63 nursing home residents were followed for 6 months and assessed for the presence of wetness or pressure ulcers. Facility costs for incontinence management were accumulated. Fifty-four percent of the residents (34 of 63) received treatments for incontinence and 60% (20 of 34) became dry. Pressure ulcer rates decreased from 16 participants developing 26 pressure ulcers to 3 participants developing 5 ulcers. Facility cost of incontinence management for 6 months was $86,436 with 46% attributed to direct labor costs. Toileting was the most expensive component, costing $36,755. Total daily cost of incontinence management was $573 ($9.09 +/- 10.52 per resident). Implementation of the incontinence protocol resulted in improved "dryness" of the participants and reduced pressure ulcer incidence.